Inpatient Coding Specialist II (Coding certification required; Inpatient Coding exp required) - REMOTE

Vanderbilt University Medical Center•Nashville, TN

3d•Remote

About The Position

Reviews documentation in the electronic medical record and assign and sequences ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes, in accordance with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and in compliance with ICD-10 Official Coding Guidelines and other regulatory requirements. Uses Diagnosis Related Groups (DRG) methodologies, including Medicare Severity DRGs (MS-DRGs) and All Patient Refined DRGs (APR-DRGs). Responsible for coding mortality and high dollar (over $400k) complex discharges and will draft physician queries, to clarify documentation for optimal coding and quality reporting.

Requirements

Coding certification required
Inpatient Coding exp required
Certified Coding Associate - American Health Information Management Association (AHIMA)
Certified Coding Specialist - American Health Information Management Association (AHIMA)
Certified Coding Specialist - Physician - American Health Information Management Association (AHIMA)
Certified Outpatient Coder - American Academy of Professional Coders
Certified Professional Coder - Outpatient - American Academy of Professional Coders
Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)
Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA)
Relevant Work Experience
High School Diploma or GED (Required)

Nice To Haves

Understanding the rules, regulations, sanctions and other statutory requirements, guidelines and instructions relating to governing bodies and organizations, both internally and externally.
The ability to comprehend medical terminology and documentation in an office, or surgical setting.
The objective analysis and evaluation of an issue in order to form a judgment.
The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos and documentation. Demonstrates an understanding of effective composition, such as having first line in a paragraph state the subject.

Responsibilities

Review, analyze and interpret the entire electronic medical record for the current admission to identify all diagnoses and procedures documented during the admission.
Determine and assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology and pathophysiology/disease processes.
Identify cases with clinical indicators that may require provider documentation clarification and/or specificity to accurately assign codes; collaborate with CDIS team as part of the clinical documentation validation and physician query workflows.
Analyze code assignment and sequence to assure proper DRG assignments; sequence codes in compliance with ICD-10 Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS) and other regulatory requirements to accurately assign the DRG.
Analyze the medical record documentation for complications and comorbidities.
Analyze medical record documentation for optimum severity of illness and risk of mortality scores.
Confirm Admission-Discharge-Transfer (ADT) information and correct when necessary.