Inpatient Coder/Abstractor Sr - Health Information Management

McLeod Health•Florence, SC

About The Position

The Senior Inpatient Coder is responsible for accurately assigning diagnosis and procedure codes to inpatient discharges at the larger McLeod Health facilities representing more complex medical/surgical encounters. Maintains credentials as RHIA, RHIT or CCS with AHIMA is required. Possess inpatient coding knowledge and experience necessary to accurately assign codes to determine correct principal diagnosis, identify and assign co-morbidities and complications, secondary diagnoses, present on admission indicator, discharge disposition, Hospital Acquired conditions, principal procedure, and secondary procedures on all discharged inpatient records to arrive at the most appropriate DRG assignment. Codes all inpatient discharges at the 2 larger McLeod Health facilities (Florence & Seacoast) with more complex medical and surgical procedures. These encounters involve longer lengths of stay, complex medical diagnoses and may involve extensive surgical procedures. These facilities provide the services like trauma, invasive cardiac, vascular, and complex orthopedic procedures that are not available at the smaller campuses Maintains department specific productivity standards with a 95% accuracy rate. Queries physicians appropriately when documentation is not clear in the medical record. Must work closely with the Clinical Documentation Specialists to assure the most optimal DRG is assigned. Keeps abreast of all new coding developments by attending any coding classes, reading articles on coding updates, and attending seminars when available. Respect patient confidentiality at all times. Performs other duties as assigned.

Requirements

1 to 2 years of inpatient coding in an acute care hospital setting
RHIT, RHIA, or CCS certification required

Responsibilities

accurately assigning diagnosis and procedure codes to inpatient discharges
assign codes to determine correct principal diagnosis
identify and assign co-morbidities and complications, secondary diagnoses, present on admission indicator, discharge disposition, Hospital Acquired conditions, principal procedure, and secondary procedures on all discharged inpatient records to arrive at the most appropriate DRG assignment
Codes all inpatient discharges at the 2 larger McLeod Health facilities (Florence & Seacoast) with more complex medical and surgical procedures
Maintains department specific productivity standards with a 95% accuracy rate
Queries physicians appropriately when documentation is not clear in the medical record
work closely with the Clinical Documentation Specialists to assure the most optimal DRG is assigned
Keeps abreast of all new coding developments by attending any coding classes, reading articles on coding updates, and attending seminars when available
Respect patient confidentiality at all times
Performs other duties as assigned