HIM CODER (OTPT)

Fort Defiance Indian Hospital Board, Inc.•Fort Defiance Agency, AZ

5d•$26 - $32

About The Position

The HIM Coder (OTPT) is responsible for retrieving information from the RPMS, reviewing medical records to ensure correct diagnosis and procedural codes are assigned by FDIHB providers. This role involves assigning and categorizing codes using various classification systems and guidelines, abstracting necessary information by auditing patient care forms and electronic health records, and performing quantitative analysis to ensure record completeness and accuracy. The position also requires quality data entry, maintaining confidentiality of patient information, coordinating workflow with clinical staff, monitoring areas for improvement, and staying updated on coding regulations and techniques. The HIM Coder will also conduct quality control reviews, work with providers on clinical documentation improvement, and maintain the integrity of patient information.

Requirements

Two (2) years of outpatient coding experience in a healthcare setting.
If no outpatient coding experience, must have a Registered Health Information Technician (RHIT) Certification.
Completion Certificate from a University/College or Technical school related to Medical Billing and Coding course (must have certification within one (1) year).
High School Diploma or Equivalency (HSE).
Coding Certification by the American Health Information Management Association (AHIMA) or, the American Academy of Professional Coders (AAPC), Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist Physician-based (CCS-P) or Coding Certification by the American Academy of Professional Coders (AAPC), Certified Professional Coder (CPC), Certified Professional Coder – Apprentice (CPC-A), Certified Outpatient Coding (COC), Certified Inpatient Coder (CIC).
Applicant must have a valid, unrestricted insurable driver’s license.
Resumes and references are required.

Nice To Haves

Completion Certificate from a University/College or Technical school related to Medical Billing and Coding course (must have certification within one (1) year).

Responsibilities

Retrieves information from the RPMS and reviews medical records to ensure correct diagnosis and procedural codes are assigned.
Assigns and categorizes codes using ICD-10-CM, ICD-10-PCS, CPT, HCPCS, coding guidelines, and other policies.
Uses the 3M Grouper System to assist in classifying diagnoses and verifying coding accuracy.
Abstracts necessary information by auditing and analyzing patient care component forms and Electronic Health records for E&M levels, CPT, and HCPCS codes.
Performs quantitative analysis to ensure the presence of all component parts of the record and evaluates records for internal consistency, completeness, and accuracy.
Identifies inconsistencies or discrepancies among medical documentation and discusses them with appropriate staff and physicians.
Performs quality data entry of protected patient health information into RPMS and 3M Grouper systems.
Performs audits and medical reviews by running error listings and other data reports.
Reviews and completes zero reports and RPMS Audit list reporting.
Ensures the validity, completion, and disposition of all clinical records briefs.
Maintains confidentiality of health information in accordance with federal regulations.
Works with clinical staff in coordinating workflow and ensuring up-to-date codes are maintained.
Surveys potential risk areas and identifies inconsistencies or discrepancies within medical records.
Monitors specific areas for improvement by recognizing potential risks related to compliance issues.
Documents findings and prepares reports for the immediate supervisor.
Performs quality assurance/performance functions for the department.
Prepares reports and presents to staff and the Quality Assurance Committee.
Completes all RCM Queries within 24 hours upon receipt.
Uses coding guidelines and resources including the Encoder (3M), ICD-10 CM, ICD 10-PCS, CPT, HCPCS, and other coding classification systems.
Conducts quality control and improvement reviews by tracking inadequate documentation, communicating software/hardware problems, and maintaining deficiency and productivity logs.
Works with clinical providers on clinical documentation improvement and coordinates to correct deficiencies.
Maintains the integrity of patient information, protecting it from unauthorized disclosures, breaches, or alterations.
Complies with FDIHB policies governing user access of accounts and ensures confidentiality.
Reports any security breaches or potential breaches to the immediate supervisor.
Keeps abreast of the latest concepts and techniques in coding, regulations, and related resources.
Continues pursuit and development of job-related interests and specialty areas.
Performs other duties as assigned.