HIM CODER

UHS•MADERA, CA

15h•Onsite

About The Position

Under the supervision of the Director of HIM (Health Information Management), the HIM Coder is responsible for coding and abstracting medical records, including all diagnoses for inpatient and partial hospitalization medical records, using the International Classification of Diseases (ICD-10-CM), and entering coded information into the MIRA computer system. Performs related work as required.

Requirements

Graduation from a HIM program preferred. High school or equivalent with knowledge of general office skills required.
RHIA or R.H.I.T required with 1 year coding experience or CCA with 2 years coding experience, or CCS or CC-P with 1 year coding experience, and at least one year of experience in a HIM department.
Knowledge of medical terminology, anatomy, physiology, and ICD-10-CM classification system is required.
Computer knowledge is helpful.
Must be able to use a computer keyboard, read medical reports, and sit for long periods of time.
Ability to work with a high degree of precision, paying attention to detail in order to achieve the high levels of accuracy required.
Ability to adhere to ethical principles relating to quality, truth, and accuracy in work performance and productivity.
Ability to organize, collect and classify diagnostic information for hospital reimbursement purposes.
Thorough knowledge of medical terminology.
Knowledge of the International Classification of Diseases (ICD-10-CM) codes; knowledge of DSM V Diagnostic Manual of Mental Disorders.
Ability to communicate effectively both orally and in writing.
Ability to be thorough.
Possesses sound judgment; discretion; and initiative.
Ability to organize and set workload priorities to meet deadlines.
Thorough understanding of the content of the medical record as well as clinical knowledge including extensive training in anatomy, physiology, pharmacology, and clinical disease process.
Ability to assess the medical record content and highlight shortcomings to management.
Ability to maintain ICD-10-CM coding books to make sure they are updated to the current version being used.
Ability to assist with the education of clinical staff with regard to ICD-10-CM and documentation requirements.
Ability to liaison with computing and finance staff.
Ability to adhere to safety policies and procedures.
Ability to work as a team player.
Ability to demonstrate resourcefulness, patience and dedication.
Ability to accept direction and adhere to policies and procedures.
Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric).
Ability to work in a fast-paced environment.
Ability to react calmly and effectively in emergency situations.
Ability to continually update skills and knowledge.

Responsibilities

Accurately codes principle diagnosis from information from inpatient medical records, utilizing ICD-10-CM classification system.
Accurately codes PSYCHIATRIC/MEDICAL diagnoses from information from inpatient medical records, utilizing ICD-10-CM classification system.
Accurately codes PSYCHOSOCIAL/ENVIRONMENTAL diagnoses from information from inpatient medical records, utilizing ICD-10-CM classification system.
Accurately codes principle diagnosis from information from outpatient medical records, utilizing ICD-10-CM classification system.
Accurately codes PSYCHIATRIC/MEDICAL diagnoses from information from outpatient medical records, utilizing ICD-10-CM classification system.
Accurately codes PSYCHOSOCIAL/ENVIRONMENTAL diagnoses from information from outpatient medical records, utilizing ICD-10-CM classification system.
Contacts attending physicians regarding questions on diagnoses needed for greater detail or different terminology in order to assign accurate codes to medical records.
Accurately enters code alpha/numbers of diagnoses into the computer system.
Ensures all diagnoses are sequenced properly.
Accurately abstracts data from discharged inpatient records and enters them into computer system.
Ensures OSHPD data is correct.
Accurately assigns attending physician.
Accurately assigns referring physician.
Accurately assigns consulting physician(s).
Insures that all factors necessary for assigning an accurate DRG (Diagnostic Related Groups) are present.
Manages work flow so that bills are dropped by the third business day.
Manages work flow so that specific insurance requirements are met.
Works with physicians so that diagnoses are present upon discharge.
Works with Business Office to assist with payment issues.
Provides information and responds to inquiries regarding medical documentation and DRGs to hospital staff.
Generates computer reports from abstracted data.
Participates in other HIM functions, as assigned.