Interventional Radiology Coder

Cleveland Clinic

3d•Remote

About The Position

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. Cleveland Clinic is recognized as one of the top hospitals in the nation. At Cleveland Clinic, you will receive endless support and appreciation and build a rewarding career with one of the most respected healthcare organizations in the world. As an Interventional Radiology Coder, you will be dedicated to either hospital inpatient or hospital outpatient coding. In this role, you will code and abstract highly complex clinical information from high-acuity inpatient charts or outpatient surgery and observation charts for reimbursement, research and compliance with federal regulations and other agencies, utilizing established coding principles and protocols. This position will help expand our in-house outpatient surgery coding team, including the ability to code and charge for interventional radiology procedures. Inpatient: Identify, review, and assign highly complex/high-acuity codes, including ICD-10-CM, PCS, POA and PSI indicators for inpatient charts. Outpatient: Identify, review and assign highly complex codes, including ICD-10-CM and CPT for ambulatory surgery and observation charts. A caregiver in this role works remotely from 7:00 a.m. -- 4:00 p.m. A caregiver who excels in this role will: Clarify highly complex discrepancies in documentation and coding. Ensure accuracy and timeliness of highly complex/high acuity coding/abstracting for inpatient charts to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care. Leverage AI tools to enhance quality and productivity and reduce manual effort in routine tasks. Monitor performance and accuracy of AI-assisted outputs, ensuring alignment with quality standards and coding guidelines. Contribute to the development of internal best practices for ethical and secure use of AI technologies. Ensure accuracy and timeliness of highly complex coding/abstracting for outpatient charts to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care. Abstract highly complex clinical information from high acuity inpatients or surgical outpatients and observations for the purpose of reimbursements, research and compliance with federal regulations and other agencies utilizing established coding principles and protocols. Accurately code high complexity/high acuity cases. Extract pertinent highly complex information from clinical notes, operative notes, radiology reports, laboratory reports, specialty forms, etc. using ICD-10-CM/PCS codes or CPT codes, POA indicators and PSI indicators. Identify medical and surgical complications and untoward events for accurate MS-DRG/APR- DRG for inpatient charts or APC assignment for outpatient charts. Follow up on highly complex/high acuity coding of medical records as a result of internal or external reviews which identified Coding, APC or DRG discrepancies. Support special studies in relation to coding and abstracting information according to policies and procedures. Maintain knowledge and skills via written coding resources, clinical information, videos, etc. Meet or exceed productivity and quality standards and established department benchmarks.

Requirements

High School Diploma
Three years of experience abstracting, identifying, reviewing and assigning highly complex/high acuity ICD-10-CM, CPT, ICD-10-PCS, POA and PSI indicators, surgical complications for inpatient, or CPT codes for surgical outpatient and observations
Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) by American Health Information Management Association (AHIMA) or Certified Interventional Radiology Cardiovascular Coder (CIRCC), Certified Professional Coder (CPC), Certified Outpatient Coder (COC) by American Academy of Professional Coders (AAPC)
Coding assessment relevant to the work may be required
Current with emerging AI technologies
Interventional Radiology, coding and charging experience

Nice To Haves

Certified Interventional Radiology Cardiovascular Coder (CIRCC)
Professional and hospital experience, with an acute care background or experience in a facility performing interventional radiology procedures

Responsibilities

Identify, review, and assign highly complex/high-acuity codes, including ICD-10-CM, PCS, POA and PSI indicators for inpatient charts.
Identify, review and assign highly complex codes, including ICD-10-CM and CPT for ambulatory surgery and observation charts.
Clarify highly complex discrepancies in documentation and coding.
Ensure accuracy and timeliness of highly complex/high acuity coding/abstracting for inpatient charts to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care.
Leverage AI tools to enhance quality and productivity and reduce manual effort in routine tasks.
Monitor performance and accuracy of AI-assisted outputs, ensuring alignment with quality standards and coding guidelines.
Contribute to the development of internal best practices for ethical and secure use of AI technologies.
Ensure accuracy and timeliness of highly complex coding/abstracting for outpatient charts to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care.
Abstract highly complex clinical information from high acuity inpatients or surgical outpatients and observations for the purpose of reimbursements, research and compliance with federal regulations and other agencies utilizing established coding principles and protocols.
Accurately code high complexity/high acuity cases.
Extract pertinent highly complex information from clinical notes, operative notes, radiology reports, laboratory reports, specialty forms, etc. using ICD-10-CM/PCS codes or CPT codes, POA indicators and PSI indicators.
Identify medical and surgical complications and untoward events for accurate MS-DRG/APR- DRG for inpatient charts or APC assignment for outpatient charts.
Follow up on highly complex/high acuity coding of medical records as a result of internal or external reviews which identified Coding, APC or DRG discrepancies.
Support special studies in relation to coding and abstracting information according to policies and procedures.
Maintain knowledge and skills via written coding resources, clinical information, videos, etc.
Meet or exceed productivity and quality standards and established department benchmarks.