HIM Coder - Medical Records - PRN

Position Status:

Shift:

Hours per week:

Job Information

Exemption Status: Non-Exempt

A Brief Overview
Reviews medical record documentation for assigning accurate ICD-10-CM diagnosis, procedure and CPT codes and chart abstracting for hospital related services, including "dual" medical coding, also known as Single Path Coding, for various specialties.

Education Qualifications

• High School Diploma / GED Required

Experience Qualifications

• 2 years Coding experience. Preferred

Skills and Abilities

• Knowledge of medical terminology. (Required proficiency)
• Knowledge of coding and regulatory guidelines. (Required proficiency)

Licenses and Certifications

• Registered Health Information Administrator (RHIA) - AHIMA Required or
• Registered Health Information Technician (RHIT) - AHIMA Required or
• Certified Coding Specialist - CCS Required or
• Certified Professional Coder - AAPC CPC also accepted. Required
• Certified Coding Associate - AHIMA CCA also accepted Required

What you will do

• Selects and assigns appropriate ICD-10-CM diagnosis, procedure and CPT codes utilizing encoding system and application following coding guidelines.
• Ensures appropriate MS-DRG/APR DRG is assigned.
• Utilizes Electronic Medical Record (EMR) to identify and enter key administrative and clinical data elements into discrete fields within the EHR.
• Comply with all legal requirements regarding coding guidelines and policies.
• Proficient with medical necessity documentation guidelines.
• Complies with payer specific guidelines for appropriate code assignment.
• Works coding queues as assigned by manager or designee.
• Collaborates with Clinical Documentation Improvement (CDI) team for clinical expertise and query opportunities.
• Submit coding queries to physicians for medical record documentation clarification.
• Converse with providers or other health care professionals on coding and/or billing practices, if needed.
• Works professionally, independently and completes assignments in a timely manner.
• Meets coding productivity and accuracy standards.
• Participates at coding and department meetings/huddles.
• Participates at CDI/Coding and other educational sessions.
• Attends All Employee Meetings.
• Continually self-educates on current coding guidelines and regulatory changes utilizing electronic reference material.

Required for All Jobs

• Complies with all policies, standards, mandatory training and requirements of Stormont Vail Health
• Performs other duties as assigned

Patient Facing Options

• Position is Not Patient Facing

Remote Work Guidelines

• Workspace is a quiet and distraction-free allowing the ability to comply with all security and privacy standards.
• Stable access to electricity and a minimum of 25mb upload and internet speed.
• Dedicate full attention to the job duties and communication with others during working hours.
• Adhere to break and attendance schedules agreed upon with supervisor.
• Abide by Stormont Vail’s Remote Worker Policy and will review and acknowledge the Remote Work Agreement annually.

Remote Work Capability

• Hybrid

Scope

• No Supervisory Responsibility
• No Budget Responsibility

Physical Demands

• Balancing: Occasionally 1-3 Hours
• Carrying: Rarely less than 1 hour
• Climbing (Stairs): Rarely less than 1 hour
• Crawling: Rarely less than 1 hour
• Crouching: Rarely less than 1 hour
• Eye/Hand/Foot Coordination: Continuously greater than 5 hours
• Feeling: Continuously greater than 5 hours
• Grasping (Fine Motor): Continuously greater than 5 hours
• Grasping (Gross Hand): Continuously greater than 5 hours
• Handling: Continuously greater than 5 hours
• Hearing: Occasionally 1-3 Hours
• Kneeling: Rarely less than 1 hour
• Lifting: Rarely less than 1 hour up to 10 lbs
• Operate Foot Controls: Rarely less than 1 hour
• Pulling: Rarely less than 1 hour up to 10 lbs
• Pushing: Rarely less than 1 hour up to 10 lbs
• Reaching (Forward): Occasionally 1-3 Hours up to 10 lbs
• Reaching (Overhead): Rarely less than 1 hour up to 10 lbs
• Repetitive Motions: Continuously greater than 5 hours
• Sitting: Continuously greater than 5 hours
• Standing: Occasionally 1-3 Hours
• Stooping: Rarely less than 1 hour
• Talking: Occasionally 1-3 Hours
• Walking: Rarely less than 1 hour

Physical Demand Comments:

Vision requirements include close vision and ability to adjust focus.

Working Conditions

• Burn: Rarely less than 1 hour
• Chemical: Rarely less than 1 hour
• Dusts: Rarely less than 1 hour
• Electrical: Rarely less than 1 hour
• Explosive: Rarely less than 1 hour
• Extreme Temperatures: Rarely less than 1 hour
• Infectious Diseases: Rarely less than 1 hour
• Mechanical: Rarely less than 1 hour
• Noise/Sounds: Occasionally 1-3 Hours
• Other Atmospheric Conditions: Rarely less than 1 hour
• Poor Ventilation, Fumes and/or Gases: Rarely less than 1 hour
• Radiant Energy: Rarely less than 1 hour
• Risk of Exposure to Blood and Body Fluids: Rarely less than 1 hour
• Risk of Exposure to Hazardous Drugs: Rarely less than 1 hour
• Hazards (other): Rarely less than 1 hour
• Vibration: Rarely less than 1 hour
• Wet and/or Humid: Rarely less than 1 hour

Stormont Vail is an equal opportunity employer and adheres to the philosophy and practice of providing equal opportunities for all employees and prospective employees, without regard to the following classifications: race, color, ethnicity, sex, sexual orientation, gender identity and expression, religion, national origin, citizenship, age, marital status, uniformed service, disability or genetic information. This applies to all aspects of employment practices including hiring, firing, pay, benefits, promotions, lateral movements, job training, and any other terms or conditions of employment.

Retaliation is prohibited against any person who files a claim of discrimination, participates in a discrimination investigation, or otherwise opposes an unlawful employment act based upon the above classifications.