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Inpatient Coder II Remote
UMass Memorial Health

Location: Long Branch, Remote
Work Setting: Hospital
Job Function:
Coder
Job Type:
Full-Time

Introduction

The Inpatient Coder II is an advanced coding position responsible for accurate and timely assignment of codes to diagnoses and procedures for all inpatient cases.  Interprets a wide variety of clinical and diagnostic documentation, including complex medical cases and treatments, to identify: diagnoses, complications, comorbidities, and procedures associated with episodes of inpatient care. Assigns appropriate Diagnosis Related Group (DRG) to each coded inpatient account to obtain optimal hospital reimbursement, Severity of Illness (SOI), and Risk of Mortality (ROM). Assigns current edition of ICD-CM, ICD-PCS, and CPT codes as appropriate adhering to official coding guidelines. Communicates directly with clinicians through the electronic medical record (EMR) query process. Assists in training of new personnel.

 

 

Experience/Skills:

 

Required:

  1. Proficient in utilizing multiple payer-specific DRG groupers as required by individual payers.
  2. Thorough knowledge of the current editions of DRG, ICD-CM, ICD-PCS, and CPT coding systems.
  3. Thorough knowledge of third-party payer requirements as well as federal and state guidelines and regulations pertaining to coding and billing practices.
  4. Excellent customer service skills with the ability to communicate efficiently.
  5. Exceptional organizational skills with attention to detail.
  6. Ability to work independently within established guidelines.
  7. Excellent oral and written communication skills.
  8. Ability to organize and coordinate multiple functions and tasks.
  9. Ability to problem solve, organize and prioritize workload to meet productivity benchmarks.
  10. Ability to withstand significant level of on-going pressure, and ability to deal with individuals with tact, discretion and diplomacy.

Preferred:

  1. Five (5) years of inpatient coding experience.

 

Job Description

  1. Major Responsibilities:

 

  1. Upon review of the medical record, performs analysis on documentation, which includes: History & Physical (H&P), progress notes, flow sheets, Provider orders, consultations, operative reports, pathology results, and additional tests / reports to determine the appropriate current edition ICD-CM diagnosis and ICD-PCS codes as defined by official coding guidelines, the Coding Clinic, and other recognized reference materials.
  2. Required to accurately assign and / or correct the discharge disposition status based on clinical documentation to ensure proper reimbursement.
  3. Assigns the correct principal diagnosis, comorbidities and complications (CCs), secondary diagnoses, POA (Present on Admission) indicators, HAC (Hospital-Acquired Conditions), principal procedure codes, and secondary procedure codes according to official coding guidelines, the Coding Clinic, and in accordance with all official Uniform Hospital Discharge Data Set (UHDDS) definitions.
  4. Based upon the assigned codes, utilizes the computerized 3M Encoder software to assign the most accurate DRG.
  5. Performs and facilitates retrospective queries when documentation is inconsistent, incomplete, ambiguous, or non-specific.
  6. Works closely with the Clinical Documentation Improvement (CDI) to improve medical record documentation.
  7. Assists in resolving incomplete and / or missing chart documentation in order to expedite coding and billing.
  8. Participates in the continuous coding audit and performance management program.
  9. Maintains DRG and coding accuracy rate of not less than 95% for optimal reimbursement as well as department productivity standards as outlined in department policies.
  10. Attends required training classes and coding in-services each year to stay abreast of new regulations and coding guidelines.
  11. Participates in improvement efforts and documentation training for medical and clinical staff as it relates to coding practices and guidelines.
  12. Communicates to direct Manager when backlog situations arise or necessary documents are either incorrect or are not being received in a timely manner.
  13. Refers all unusual, questionable situations to the Inpatient Coder Lead or Supervisor of Inpatient Coding. Alerts management to any coding irregularities, or trends contrary to policies and procedures, so corrective measures may be taken.
  14. Adheres to the coding and billing regulations established by the American Hospital Association (AHA), American Medical Association (AMA), and Centers for Medicare and Medicaid Services (CMS).
  15. Maintains direct and ongoing communications with other coding personnel to maximize overall effectiveness and efficiency of the operation.
  16. Assists the Manager in training new personnel and when directed serves as a resource for fellow employees
  17. Keeps current with all coding updates and information related to correct coding.

 

Required Qualifications

License/Certification/Education:

 

Required:

  1. Level of knowledge equivalent to an Associate or bachelor’s degree in Health Information Management.
  2. Certification(s) as a Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Coding Specialist – Physician (CCS-P), or Certified Inpatient Coder (CIC) required upon hire.

 

Experience/Skills:

 

Required:

  1. Proficient in utilizing multiple payer-specific DRG groupers as required by individual payers.
  2. Thorough knowledge of the current editions of DRG, ICD-CM, ICD-PCS, and CPT coding systems.
  3. Thorough knowledge of third-party payer requirements as well as federal and state guidelines and regulations pertaining to coding and billing practices.
  4. Excellent customer service skills with the ability to communicate efficiently.
  5. Exceptional organizational skills with attention to detail.
  6. Ability to work independently within established guidelines.
  7. Excellent oral and written communication skills.
  8. Ability to organize and coordinate multiple functions and tasks.
  9. Ability to problem solve, organize and prioritize workload to meet productivity benchmarks.
  10. Ability to withstand significant level of on-going pressure, and ability to deal with individuals with tact, discretion and diplomacy.

Preferred:

  1. Five (5) years of inpatient coding experience.

Instructions for Resume Submission

Apply on line at www.ummhealth.org

 

 

Apply Online: https://www.ummhealth.org

Posted: November 30, 2022 at 7:39 AM
Post ID: 73390

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