Internal Auditor Coder - Full-time with Benefits

Frederick Health•Frederick, MD

5d•Onsite

About The Position

Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior. Audits, codes and abstracts inpatient and outpatient medical records of all types and, following a rigorous review of the clinical documentation, abstracts and assigns appropriate ICD-10-CM/PCS code sets and assigns the correct APR-DRG into the hospital information system. May also participate in other Special Projects as assigned by the Coding Manager.

Requirements

PC experience; ability to use computer terminals for prolonged periods to enter data.
Ability to work under time and productivity constraints.
Ability to work with frequent distractions/interruptions.
Ability to read records and handwriting of differing levels of legibility for prolonged periods.
Attention to detail.
Good organizational skills.
Ability to sit for prolonged periods.
Ability to reach, bend, lift, and carry medical records.
Good public relations and communication skills.
Good judgment when dealing with others.
High School Diploma or GED required.
Completion of a Coding Certificate Program is required.
At least one of the following: CCS (Certified Coding Specialist), RHIA or RHIT credential is required
Candidate must also have 5-7 years of experience coding inpatient Medical Records in an Acute Care Hospital using both ICD-10-CM and CPT.
Demonstration of skills through completion of a hospital administered advanced coding test with a satisfactory score.

Nice To Haves

Ability in Report Writing and use of Excel Spreadsheets.
Combination of coding, auditing, CDI or nursing experience preferred.

Responsibilities

Audits both inpatient and outpatient records of all patient types for completeness of coding and determination of the clinical significance of codes assigned.
Provide education and feedback to staff.
Determines the correct principal diagnosis, identifies and assigns co-morbidities and complications, secondary diagnoses, present on admission indicators for ICD-10-CM and MHACs (Maryland Hospital Acquired conditions), principal procedure codes and secondary procedure codes.
Assigns the appropriate APR-DRG.
Identifies and correctly codes and sequences ICD-10- CM/PCS diagnoses and procedure codes for appropriate optimal reimbursement.
Works in collaboration with CDI to ensure that the MHACS (Maryland Hospital Acquired Conditions) and PQIs (Prevention Quality Indicators) are correctly assigned.
Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information.
Protects confidential medical information following HIPAA guidelines.
Accurately abstracts the Attending Physician, Discharge Disposition and location Discharged to, Consultations, Ambulance Run Number & County codes, Date (s) of surgery or other procedures, Cause of Death if applicable, and Anesthesiologist
Writes compliant Queries to the physician when documentation is not clear or incomplete.
Participates in an Abstract Peer Review to ensure that the abstract elements are correct.
Works in collaboration with other departments including Registration, Patient Financial Services, Lab, Pathology and Medical Records.
Participates in Special Projects to include the Aging report or review of denials.
Meets Productivity Standards on a daily basis.
Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participating in continuing education programs to effectively apply ICD-10-CM and CPT coding guidelines to inpatient and outpatient diagnoses and procedures.
Identifies the correct location in the medical record to obtain pertinent information such as (i.e. BMI, Hemodialysis, Blood Transfusion, Pressure Ulcers, Isolation, Mechanical Ventilation and orders.
Keeps up-to-date on the HSCRC guidelines and state and national specific coding updates and guidelines.
Maintain a thorough understanding of medical record practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO) and HSCRC (Health Services and Cost Review Commission).