Outpatient Coder - HIM Specialist

Mary Free Bed Rehabilitation Hospital•Grand Rapids, MI

About The Position

The Outpatient Coder reviews outpatient clinical documentation and diagnostic results as appropriate, extracts relevant information, and applies ICD-10-CM codes for billing, internal and external reporting, research, and regulatory compliance. Under the direction of the Manager of Health Information Management, the role accurately codes outpatient conditions and procedures in accordance with the ICD-10-CM Official Guidelines for Coding and Reporting. The role also supports record completion, resolves documentation questions with providers, and assists physicians, therapists, hospital staff, patients, and families with health information issues. It contributes to customer service and quality improvement efforts and may perform additional tasks such as chart audits, compliance analysis, and scanning.

Requirements

Associate degree or equivalent training through at least two years of progressive on-the-job experience in a professional medical office or hospital setting.
RHIA, RHIT, CCS, CCA, or CPC certification.
Advanced understanding of anatomy and physiology, medical terminology, and record documentation requirements.
Familiarity with health information management principles and practices and their application to hospital records and coding.
Strong interpersonal skills, including oral and written communication.
Time-management skills to handle 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 style and open communication, including with other departments and sites.
Self-directed, organized, and able to reason objectively.
Ability to work independently and in a group in a multitasking environment.
Excellent analysis and problem-solving skills.
Demonstrated commitment to the organizational mission and a “whatever it takes” attitude.
Credible and trustworthy.
Information-management skills and 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 or mentoring with complicated case files.
Collaborate with Outpatient Utilization Review Specialists when coding review is needed for complicated coverage situations.
Seek clarification or additional documentation from therapists and other providers before code assignment when health-record information is conflicting, incomplete, or ambiguous.
Provide general health-information assistance to physicians, therapists, hospital staff, patients, and families.
Provide training to new health information staff, students, or residents as assigned.
Report record deficiencies for chart-completion and reporting purposes; investigate charts with missing information using independent judgment.
Work with medical and professional staff to ensure timely record completion and provide follow-up when needed.
Perform other duties assigned by leadership, which may include chart audits, analyzing records for accreditation compliance, and scanning.
Demonstrate excellent customer service and standards of behavior, and encourage, coach, and monitor these standards in team members.
Promote teamwork and direct communication with coworkers and handle confidential information discreetly and sensitively.
Identify problems and seek solutions, promote patient and family satisfaction, and participate in departmental customer-service monitoring and reporting.