Inpatient Coder II

Riverside Hospital•Newport News, VA

3d•Remote

About The Position

The Inpatient Coder II is responsible for analyzing the medical record to assign International Classification of Diseases (ICD) Clinical Modification (CM) diagnoses and Procedure Coding System (PCS) codes to ensure correct code assignment and optimal reimbursement in compliance with state and federal guidelines. Works in collaboration with the Clinical Documentation Improvement (CDI) team to ensure accurate Diagnosis Related Group (DRG) assignment and works closely with management to resolve problems and meet deadlines.

Requirements

High School Diploma or GED
3-4 years Active Inpatient Coding (Acute Care)
Extensive knowledge of medical terminology, the human disease process, clinical science, anatomy and physiology, pathophysiology and laboratory medicine.
Ability to communicate clearly and concisely verbally and in writing to ensure that the intended audience understands the information and the message.
Ability to listen and respond appropriately to others.
Ability to present information in an organized and professional manner.
Knowledgeable in Microsoft Office, use of encoder (3M 360 preferred) and use of an electronic medical record (EMR) (EPIC preferred).
Certified Coding Specialist (CCS) - The American Health Information Management Association (AHIMA) or Certified Coding Associate (CCA) - The American Health Information Management Association (AHIMA) or Registered Health Information Administrator (RHIA) - The American Health Information Management Association (AHIMA) or Registered Health Information Administrator (RHIT) - The American Health Information Management Association (AHIMA) or Certified Inpatient Coder (CIC) - American Academy of Professional Coders (AAPC)

Nice To Haves

Program Graduate, Health Information Management Services (HIMS) or related

Responsibilities

Assigns International Classification of Diseases (ICD)-10-CM Clinical Modification (CM) and ICD-10-Procedure Coding System (PCS) codes creating diagnosis-related group (DRG) assignments.
Abstracts pertinent information from patient records.
Sequences the diagnosis and procedures using coding guidelines and optimizing the diagnosis-related group (DRG) as applicable.
Apply present on admission (POA) indicators and verify the discharge disposition is correct on all inpatient accounts.
Communicates with Clinical Documentation Improvement (CDI) on mismatches to include diagnosis-related group (DRG), principal diagnosis selection, complication or comorbidities (CC), major complication or comorbidities (MCC), hospital acquired conditions (HAC), patient safety indicators (PSI), and severity of illness and risk of mortality (SOI/ROM) on reviewed cases.
Identifies the need for clinical validation and works with the Clinical Documentation Improvement (CDI) department to review documentation and/or request provider documentation clarification.
Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous or unclear for coding purposes.
Maintains four-day turnaround times for inpatient coding based on the discharge date and total charges, while meeting productivity standards.
Collaborates with other departments to meet departmental monthly goals which include one or more of the following: DNFB (discharged not final billed), Denials, and Claim Edits.
Participates in ongoing coding educational webinars routinely and as needed.
Reviews individually audited cases by third party companies and/or internal audits and provide a rebuttal if needed.
Participates in the development of coding policies and procedures.