United States onlyDescription
Nemours is seeking a Coder! This position is responsible for the proper coding and abstracting of inpatient facility medical records using ICD-10-CM diagnosis and PCS codes in accordance with ICD 10 CM and PCS coding conventions and the Official Guidelines for Coding and Reporting.
Knowledge and adherence to the Official Coding Guidelines for ICD 10 CM and PCS is required. Participation in on-going coding training and education is essential and required for this position. Maintaining annual coding certification through the American Health Information Management Association (AHIMA) or the AAPC is also required.
Responsibilities:
Translate diagnostic and procedural documentation into the appropriate ICD-10-CM, PCS, SOI, and ROM assignments
Select the appropriate principal diagnosis code, secondary diagnoses, and procedure codes according to the UHDDS.
Analyze the circumstances of admission to ensure proper sequencing, selection of discharge disposition, and Present on Admission (POA) assignment.
Appropriate capture Complications and Comorbidities.
Ensure appropriate DRG assignment.
Identify cases that require further clarification based on the clinical indicators in the record.
Communicate and work with the Clinical Documentation Specialist.
Review medical record information using Epic.
Abstract records in an accurate manner according to established procedures and guidelines.
Meet and/or exceed coding quality and productivity standards.
Review and address coding validation edits, 3M edits, and participate in Coding Prebill reviews as well as peer reviews.
Demonstrate and incorporate a working knowledge of the Epic system for retrieval of clinical data for coding purposes.
Assist with coding shadowing and cross training as needed.
Qualifications:
High School Diploma required; Associate Degree is preferred.
Certified Coding Specialist Certification (CCS), Certified Inpatient Coder (CIC), or CPC is required.
Minimum one year coding experience is required.
Knowledge of the Official Coding Guidelines for ICD 10 CM and PCS is required.
Previous experience with All Patient Refined (APR) Diagnostic Related Groups (DRGs) is preferred.
Pediatric inpatient coding experience is preferred.
