HIM Coder - Full Time, Days (Tustin)

About the position

The HIM Coder codes and abstracts clinical and demographic data from patient records to support reimbursement and reporting. Assists in maintaining accurate and complete medical records in accordance with hospital policies and procedures. Reviews records for completeness, accuracy and compliance with regulations.

Responsibilities

• Reviews, codes and abstracts, utilizing ICD-10 and CPT coding conventions, electronic health records of hospital(s) and clinic(s) patients, both retrospectively and concurrently, in a manner consistent with administrative, ethical, legal and regulatory requirements and to meet company established DNFB standards.
• Monitors incoming records daily and provides timely coding according to policy.
• Maintains strictest confidentiality of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
• Reviews the medical record to assure specificity of diagnoses, procedures and appropriate / optimal reimbursement for hospital and/or professional charges.
• Ensures DRG/APC assignment is accurate.
• Follows through and requests missing documents/information.
• Maintains coding data quality and integrity.
• Abstracts information and statistical data from coded records.
• Ensures timely completion of history & physical and operative/procedure reports in accordance with governing / regulatory / accrediting agencies regulations.
• Accurately prepares documents/forms/queries and ad hoc report/projects in a timely manner.
• Reads and responds to emails in a timely manner.

Requirements

• 5 years as a coder in an acute care hospital
• High School Diploma or GED
• RHIT and/or RHIA and/or CCS or CPC certification
• Excellent written and verbal communication skills in English
• Ability to multitask and maintain a work pace appropriate to workload
• Computer literacy and proficiency
• Must demonstrate customer service skills appropriate to the job