Hospital Inpatient Coder

Best Care•Omaha, NE

6d•Onsite

About The Position

Responsible for reviewing all patient files for accuracy, and coding that information into the computer system so that the records will indicate all relevant data.

Requirements

Requires college level completion of courses in anatomy and physiology, biology, disease process and medical terminology.
Requires a Health Information Management degree and/or related health care degree (associate's degree or bachelor's degree) or five years prior coding experience.
Requires knowledge of ICD-9CM/ICD-10-CM (after 10/1/2014) coding nomenclature which may be acquired through completion of coding course or 4+ years coding experience.
Experience with personal computer.
Minimum of a Registered Health Information Technologist (RHIT), Certified Coding Specialist (CCS), Certified Coding Associate (CCA), or Certified Professional Coder (CPC) required.
Analytical ability and ability to note detail when reviewing the medical records and verifying the diagnosis.

Nice To Haves

Previous coding experience preferred.

Responsibilities

Assigns ICD-10-CM codes to inpatients, and acute rehab inpatients medical records to ensure maximum reimbursement and a valid data base utilizing Uniforms Hospital Discharge Data Set (UHDDS) definitions of principal and secondary diagnosis and principles of code assignment.
Assign appropriate physician name/date to any procedures coded in the Optum Computer Assisted Coding program and adds the appropriate Present On Admission (POA) indicators to appropriate ICD-10-CM diagnoses.
After completion Diagnosis Related Group (DRG) grouping and save to final to generate claim for timely claim submission.
Ensures the availability of diagnosis and procedure codes to allow for the timely submission of claims to insurance companies by performing job functions #1 and #2 within defined productivity expectations.
Review and make appropriate changes if applicable to discharge disposition on inpatient claim.
Assist the Clinical Documentation Specialists to identify opportunities to query the physician for additional documentation.
Work with the Clinical Documentation Specialists to generate compliant queries to send to the physicians when documentation needs further clarification to ensure clear compliant documentation and maximum reimbursement.
Updates the Optum Computer Assisted Coding tool with the Final DRG or with any queries that are submitted.
Work with the Clinical Documentation Specialists on concurrent coding to generate the working Diagnosis Related Group (DRG), Geometric Mean Length of Stay (GMLOS), and provide information to the Coding Sequence (CDS) when a query needs to be generated from a coding or clinical clarity perspective.