Inpatient Coder 3 Certified / HIM Coding

Hartford HealthCare-posted 3 months ago
Full-time • Mid Level
Farmington, CT
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The position involves reviewing inpatient clinical documentation to determine the appropriate assignment of alpha numeric diagnosis/procedure codes and Medicare Severity Diagnosis Related Groups (MS-DRG). The data is classified for internal and external statistical reporting, research, regulatory compliance, and reimbursement. The role includes coding high dollar and multifaceted accounts, which encompasses interventional radiology, interventional cardiology, cardiovascular surgeries, major transplants, neurovascular surgeries, spinal fusions, and coding level 1 trauma cases.

  • Applies strong knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to determine the appropriate assignment of diagnosis and procedure codes for more complex accounts.
  • Analyzes medical records using the Uniform Hospital Discharge Data Set (UHDDS), interprets documentation and assigns proper ICD-10-CM diagnoses and ICD-10-PCS operative procedure codes utilizing designated software.
  • Reviews DRG assigned to each record, enters coded/abstracted information into software, analyzes DRG groupings, and observes for appropriate DRG assignment.
  • Reviews high dollar and more complex cases including medical, surgical, behavioral health, and IP Rehabilitation.
  • Applies IRF-PAI guidelines for IP Rehabilitation coding.
  • Adheres to all department coding procedures, policies, guidelines, and quality standards.
  • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association/American Association of Procedural Coders.
  • Meets revenue cycle goals (KPIs and Productivity Standards).
  • Completes on a daily basis cases that have been assigned for review of edits.
  • Collaborates with clinical documentation specialists (CDS) to determine appropriate DRG assignment for compliance and reimbursement purposes.
  • Collaborates with Quality Management and other departments as required.
  • Seeks clarification from attending physician in cases where documentation is absent, ambiguous, or contradictory.
  • Assists in training and mentoring new coders to become acclimated to the new environment and understand internal coding policies and procedures.
  • Associate's Degree or equivalent experience.
  • Minimum of two to three years of progressive on-the-job experience in an acute care hospital.
  • Certified Coding Specialist (CCS) required and maintained thereafter.
  • Strong written and verbal communication skills.
  • Strong knowledge of ICD-10-CM diagnostic and ICD-10-PCS procedure codes.
  • Strong knowledge of UHDDS and various DRG methodologies (MS-DRG, APR-DRG, Tricare, etc.).
  • Strong knowledge of IP Rehabilitation coding rules for IRF-PAI.
  • Proficient in Microsoft Office Products; Word, Excel.
  • Proficient in Encoder and/or CAC.
  • Two to four years of progressive on-the-job experience in an acute hospital.
  • Competitive benefits program designed to ensure work/life balance.
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