Outpatient Coder - HIM Specialist

Mary Free Bed Rehabilitation Hospital•Grand Rapids, MI

About The Position

Review outpatient clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-10-CM codes for billing, internal and external reporting, research, and regulatory compliance. Under the direction of the manager of Health Information Management, accurately code outpatient conditions and procedures according to the ICD-10-CM Official Guidelines for Coding and Reporting. The role also provides general assistance on health information issues, supports record completion and compliance, and contributes to customer service and quality-improvement efforts. Mary Free Bed is a not-for-profit rehabilitation hospital and network focused on restoring hope and freedom through rehabilitation.

Requirements

Associate degree or equivalent training, including at least two years of progressive on-the-job experience in a professional medical office or hospital setting.
One of the following certifications: RHIA, RHIT, CCS, CCA, or CPC.
Advanced understanding of anatomy and physiology, medical terminology, and record documentation requirements.
Familiarity with HIM principles and practices and their application to hospital records and coding.
Strong oral and written interpersonal skills.
Time-management skills to handle multiple competing demands and priorities and work effectively under pressure.
Intermediate knowledge of Microsoft Office, including Word, Excel, and PowerPoint.
Ability to learn quickly and ask discerning questions.
Sense of urgency and ability to adapt quickly to changing priorities.
Collaborative team approach and open communication, including with other departments and sites.
Self-directing, organized, and able to reason objectively.
Ability to work independently and in a group in a multitask environment.
Excellent analysis and problem-solving skills.
Demonstrated commitment to the organizational mission and a “whatever it takes” approach to getting the job done.
Credible and trustworthy.
Information-management skills, including the ability to interpret, communicate, and present data.

Nice To Haves

One year of outpatient coding experience in a hospital or physician office setting.

Responsibilities

Assign diagnosis, treatment, and procedure codes for outpatient encounters using the appropriate classification system.
Apply technical coding principles to assign appropriate ICD-10-CM diagnosis codes.
Follow AHIMA Standards of Ethical Coding and official coding guidelines.
Consult the Coding Specialist – HIM Team Lead for assistance with complicated case files.
Collaborate with Outpatient Utilization Review Specialists when coding review is needed for complicated coverage situations.
Contact providers for clarification or additional documentation before code assignment when the health record contains conflicting, incomplete, or ambiguous information.
Provide general assistance to physicians, therapists, hospital staff, patients, and families regarding health information issues.
Provide training to new health information staff, students, or residents as assigned.
Report record deficiencies for chart completion and reporting; investigate charts with missing information and follow up with medical or professional staff to support timely record completion.
Perform other duties assigned by leadership, which may include chart audits, record-compliance analysis, and scanning.
Demonstrate excellent customer service and standards of behavior; encourage, coach, and monitor these standards in team members.
Promote teamwork and direct communication, and handle confidential information discreetly and sensitively.
Identify problems and seek solutions as part of quality improvement; promote patient and family satisfaction and participate in monitoring and reporting customer service.