Lead Inpatient Coder

Houston Methodist•Katy, TX

About The Position

Promotes a positive work environment and leads the team to be dynamic and a focused work unit that actively helps one another to achieve optimal department results. 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 on official coding guidelines. Serves as preceptor, mentor, and resource to less experienced staff. Orients, guides, and mentors team members to help build confidence and competency in skills, knowledge, and abilities for various department tasks. Role models to team members effective communication skills, assisting in their development of such skills. Coordinates staff schedules, as appropriate, to provide daily staff coverage to promote/maintain smooth department operations. Role models healthy work relationships such as mitigation of conflict, leading problem-solving and resolution efforts. Recommends initiatives to improve department scores for employee engagement. Responds promptly to internal and external customer requests. Responds promptly and appropriately to requests to code or review coded accounts for accuracy. Serves as liaison between team members, management and physicians resolving routine matters, informing or escalating to management as needed. Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process. Assigns diagnostic and procedural codes to encounters of high complexity. Maintains and achieves departmental standards of coding quality by assigning accurate ICD-9-CM/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 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. Conducts quality audits on processes, outcomes, and team member performance. Documents, develops, and evaluates processes and procedures. Identifies opportunities for corrective action and process improvement, collecting data and performing analyses. Follows up on action items to ensure completion of assignments, ensuring all deadlines are met. Assists with implementation and education of department-based initiatives, standards of practice and protocols. Contributes towards improving department quality scores. Utilizes time effectively. Consistently codes and abstracts at or above departmental standards of productivity while ensuring accuracy of coding. Supports meeting organizational goal for Accounts Receivables (AR) associated with uncoded accounts by maintaining coding timeframes within established departmental standards and ensuring all work items assigned to the coding queues are processed in a timely manner. Monitors staffing and recommends adjustment in staff work assignments and schedules to support fluctuations in work volumes and ensure efficient labor cost utilization; minimizes team incidental overtime. Reviews team member's timecards for accuracy and management approval as directed. Utilizes own time efficiently and helps other team members. Critically evaluates her or his own performance, accepts constructive criticism, and looks for ways to improve. Identifies innovative solutions for quality improvement and process improvement to make processes work better for the department. Fosters a positive and constructive teaching environment by engaging co-workers in learning opportunities that are valuable and in alignment with business objectives.

Requirements

Associate's degree or higher in a Commission on Accreditation for Health Informatics and Information Management accredited program required or additional two years of experience (in addition to the minimum experience requirements listed below) required in lieu of degree
Five years of relevant inpatient coding experience
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
Knowledge of an electronic medical record and imaging systems
Working knowledge of medical terminology, anatomy and physiology
Proficiency with electronic encoder application
Extensive PC knowledge - must be able to work effectively in common office software, coding software and abstracting systems
Strong interpersonal, teamwork, training, mentoring, and leadership skills
Ability to adapt to multiple ongoing priorities with minimal supervision, including organizing workflow and actively participating in problem-solving

Responsibilities

Promotes a positive work environment and leads the team to be dynamic and a focused work unit that actively helps one another to achieve optimal department results.
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 on official coding guidelines.
Serves as preceptor, mentor, and resource to less experienced staff.
Orients, guides, and mentors team members to help build confidence and competency in skills, knowledge, and abilities for various department tasks.
Role models to team members effective communication skills, assisting in their development of such skills.
Coordinates staff schedules, as appropriate, to provide daily staff coverage to promote/maintain smooth department operations.
Role models healthy work relationships such as mitigation of conflict, leading problem-solving and resolution efforts.
Recommends initiatives to improve department scores for employee engagement.
Responds promptly to internal and external customer requests.
Responds promptly and appropriately to requests to code or review coded accounts for accuracy.
Serves as liaison between team members, management and physicians resolving routine matters, informing or escalating to management as needed.
Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process.
Assigns diagnostic and procedural codes to encounters of high complexity.
Maintains and achieves departmental standards of coding quality by assigning accurate ICD-9-CM/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 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.
Conducts quality audits on processes, outcomes, and team member performance.
Documents, develops, and evaluates processes and procedures.
Identifies opportunities for corrective action and process improvement, collecting data and performing analyses.
Follows up on action items to ensure completion of assignments, ensuring all deadlines are met.
Assists with implementation and education of department-based initiatives, standards of practice and protocols.
Contributes towards improving department quality scores.
Utilizes time effectively.
Consistently codes and abstracts at or above departmental standards of productivity while ensuring accuracy of coding.
Supports meeting organizational goal for Accounts Receivables (AR) associated with uncoded accounts by maintaining coding timeframes within established departmental standards and ensuring all work items assigned to the coding queues are processed in a timely manner.
Monitors staffing and recommends adjustment in staff work assignments and schedules to support fluctuations in work volumes and ensure efficient labor cost utilization; minimizes team incidental overtime.
Reviews team member's timecards for accuracy and management approval as directed.
Utilizes own time efficiently and helps other team members.
Critically evaluates her or his own performance, accepts constructive criticism, and looks for ways to improve.
Identifies innovative solutions for quality improvement and process improvement to make processes work better for the department.
Fosters a positive and constructive teaching environment by engaging co-workers in learning opportunities that are valuable and in alignment with business objectives.