Coder Inpatient
About The Position
Responsible for abstracting, coding, sequencing and interpreting the clinical information from inpatient, outpatient, emergency department, pro fee and clinical medical records. Responsible for the assignment of correct principal diagnoses, secondary diagnoses and principal procedure and secondary procedure codes with attention to accurate sequencing. Utilizes technical coding principals and DRG/APC reimbursement expertise to assign appropriate codes. Abstracts and codes pertinent medical data into multiple software programs and/or encoders. Follows official coding guidelines to review and analyze health records. Maintains compliance with both external regulatory and accreditation requirements, and with State and Federal regulations. Extracts pertinent data from the patient’s health record, and determines appropriate coding for reports and billing documents. Identifies codes for reporting medical services, procedures performed by physicians. Enters codes into various computer systems dependent upon the various clients. Track and document productivity in specified systems, maintain productivity levels as defined by the client. Maintain 95% quality rating Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance.
Requirements
- Successful completion of an AAPC or AHIMA-approved Coding Certificate Program.
- Minimum of two to four years of current production coding experience in both acute care and profee.
- 3-5 years' experience in Inpatient Cancer Coding.
- CCS Required; RHIA/RHIT, CPC, or COC acceptable, but ONLY in conjunction with a CCS and 2-3 years of inpatient coding experience.
- Experience with Athena is required.
- Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes.
- Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation.
- Skill in operating a personal computer and utilizing a variety of software applications.
- Must have the following certificates and/or licenses: CPC, COC, CIC, RHIA, RHIT, CCS, and/or CCS-P.
Nice To Haves
- Altera Sunrise and Mosaic are preferred.
- Through understanding of NCI guidelines, SEERS training, and Vizient mortality models.
Responsibilities
- Abstracting, coding, sequencing and interpreting clinical information from medical records.
- Assigning correct principal diagnoses, secondary diagnoses, principal procedure, and secondary procedure codes with accurate sequencing.
- Utilizing technical coding principals and DRG/APC reimbursement expertise.
- Abstracting and coding medical data into software programs and/or encoders.
- Reviewing and analyzing health records according to official coding guidelines.
- Maintaining compliance with regulatory, accreditation, State, and Federal regulations.
- Extracting pertinent data from patient health records for coding.
- Identifying codes for reporting medical services and procedures.
- Entering codes into various computer systems.
- Tracking and documenting productivity and maintaining productivity levels.
- Maintaining a 95% quality rating.
- Performing duties in compliance with Company policies, including HIPAA and compliance.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
Associate degree
