Inpatient Coder

Houston Methodist•Los Angeles, CA

42d

About The Position

At Houston Methodist, the Inpatient Coder position is responsible for ensuring diagnostic and procedure codes are assigned accurately to inpatient encounters based upon documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines. This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

Requirements

Associate's degree or higher in a CAHIIM accredited program or additional two years of experience (in addition to the minimum experience requirements listed below) in lieu of degree
One year of relevant inpatient coding experience or successful completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program
Must have one of the following: • RHIT - Certified Health Information Technician (AHIMA) • RHIA - Registered Health Information Administrator (AHIMA) • CCS - Certified Coding Specialist (AHIMA)
Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
Knowledge of coding classification systems, DRG and APC systems, official coding guidelines and coding compliance
Working knowledge of medical terminology, anatomy and physiology
Extensive PC knowledge - must be able to work effectively in common office software, coding software and abstracting systems

Nice To Haves

Knowledge of an electronic medical record and imaging systems preferred
Proficiency with electronic encoder application preferred

Responsibilities

Interacts and communicates effectively with members of the coding team and the appropriate stakeholders.
Participates and provides good feedback during coding section meetings and coding education inservices as well as takes initiative to assist others and shares knowledge with the appropriate stakeholders.
Responds promptly to internal and external customer requests.
Responds promptly and appropriately to requests to code or review coded accounts for accuracy.
Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process.
Maintains and achieves the highest standards of coding quality by assigning accurate/ICD-10-CM/ICD-10-PCS codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines.
Maintains and achieves department standards of abstracting quality by reviewing accurate discharge disposition entered by nursing and corrects if necessary in order to achieve the highest quality of entered data.
Assigns and enters physician identification number and procedure date correctly in the medical record abstracting system.
Reviews medical record documentation and abstracts data into the encoder and EPIC/Electronic Health Record (EHR) to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions and procedures.
Utilizes all tools/ resources for accuracy.
Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official guidelines.
Utilizes time effectively.
Consistently codes and abstracts at departmental standards of productivity while ensuring accuracy of coding.
Supports meeting organizational goal for Accounts Receivables (AR) associated with uncoded accounts.
Maintains coding timeframes within established departmental standards by ensuring all work items assigned to the coding queues are processed in a timely manner.
Critically evaluates her or his own performance, accepts constructive criticism, and looks for ways to improve.
Displays initiative to improve relative to job function.
Contributes ideas to help improve quality of coding data and abstracting data.