Health Information Coder (Remote Candidates Considered)

Cape Cod Healthcare • Plymouth, MA

66d • Remote

About The Position

The position involves analyzing, sequencing, and validating assigned codes based on medical record documentation using automated encoders and coding compliance resources. The coder must demonstrate a complete understanding of coding rules, anatomy, physiology, and medical terminology to appropriately code patient information. Responsibilities include reviewing medical records to assign diagnoses, procedures, level codes, and modifiers, ensuring compliance with coding regulations and reimbursement requirements. The coder will also abstract and enter relevant patient information into medical record systems, assess documentation adequacy, and query healthcare providers for clarification when necessary. Maintaining a high accuracy rate and productivity standards is essential, along with assisting in the orientation of new coding personnel and pursuing ongoing professional development.

Requirements

• Ability to read, write and communicate in English.
• Current CCS (AHIMA Certified Coding Specialist).
• 6 months of PC windows experience.
• 2 years CCH outpatient coding experience as an Outpatient Health Information Coding and Reimbursement Specialist.
• 6 months coding experience in one of the following outpatient specialties: Pain Management, Surgical Day Care, Oncology, Radiation or Observation.
• 6 months of inpatient coding experience.
• Successful passage of Medical Record Department Inpatient Coding exam with a grade of 80% or better.

Responsibilities

• Analyzes, sequences and validates assigned codes based on medical record documentation using the automated encoder, book and coding compliance resources.
• Demonstrates complete understanding of coding rules, anatomy, physiology, and medical terminology to appropriately code patient information.
• Reviews all medical record documentation to determine and assign diagnoses, procedures, level codes and modifiers, to ensure appropriate coding for case mix.
• Selects the appropriate reimbursement grouper based on financial class for the particular account.
• Ensures that coding compliance, regulatory and reimbursement requirements are met through the process of assigning reimbursement classifications.
• Abstracts and enters diagnosis, procedures and level codes with demographic, clinical and related patient information into the Medical Record Abstracting and/or Billing/Accounts Receivable systems.
• Assesses adequacy of documentation and queries physicians and other healthcare providers to obtain additional medical record documentation or to clarify documentation to ensure accurate and appropriate coding and grouping.
• Reconciles, identifies and retrieves medical records to be coded, grouped and abstracted in accordance with departmental procedures.
• Maintains a 95% ongoing accuracy rate based on Medical Record Department performance monitors and third party validation audits.
• Consistently achieves weekly coding output within the minimal productivity standards set by HIS.
• Self-manages and prioritizes work flow to achieve timely submission of claims and optimal productivity.
• Maintains accurate productivity logs and provides this information to the Coding Manager in a timely fashion.
• Assists in the orientation and development of new coding personnel.
• Assumes professional responsibility for development of skills and ongoing education to maintain certification.
• Remains abreast of developments in health information management by pursuing a program of professional development, attending educational programs and meetings and reviewing pertinent literature.
• Continuously monitors medical record documentation, 3M coding system, Soarian Financials system, SSI claim scrubber system, individual performance and department workflow as related to the coding function to identify problems and potential solutions.
• Communicates with the Coding Manager to find solutions and implement changes to increase productivity and department efficiency.
• Performs all duties and interacts with others in accordance with the Hospital's Customer Service standards.
• Performs other work related duties as assigned or requested.

What This Job Offers

• Industry: Hospitals
• Number of Employees: 5,001-10,000 employees