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Organization:
HIM - CodingJob Summary:
JOB SUMMARYReviews documentation in the electronic medical record and assign and sequences ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes, in accordance with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and in compliance with ICD-10 Official Coding Guidelines and other regulatory requirements. Uses Diagnosis Related Groups (DRG) methodologies, including Medicare Severity DRGs (MS-DRGs) and All Patient Refined DRGs (APR-DRGs). Responsible for coding mortality and high dollar (over $400k) complex discharges and will draft physician queries, to clarify documentation for optimal coding and quality reporting.
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KEY RESPONSIBILITIES
- Review, analyze and interpret the entire electronic medical record for the current admission to identify all diagnoses and procedures documented during the admission.
- Determine and assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology and pathophysiology/disease processes.
- Identify cases with clinical indicators that may require provider documentation clarification and/or specificity to accurately assign codes; collaborate with CDIS team as part of the clinical documentation validation and physician query workflows.
- Analyze code assignment and sequence to assure proper DRG assignments; sequence codes in compliance with ICD-10 Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS) and other regulatory requirements to accurately assign the DRG.
- Analyze the medical record documentation for complications and comorbidities.
- Analyze medical record documentation for optimum severity of illness and risk of mortality scores.
- Confirm Admission-Discharge-Transfer (ADT) information and correct when necessary.
TECHNICAL CAPABILITIES
- COMPLIANCE (Advanced): Understanding the rules, regulations, sanctions and other statutory requirements, guidelines and instructions relating to governing bodies and organizations, both internally and externally.
- MEDICAL TERMINOLOGY & DOCUMENTATION (Expert): The ability to comprehend medical terminology and documentation in an office, or surgical setting.
- CRITICAL THINKING (Advanced): The objective analysis and evaluation of an issue in order to form a judgment.
- MEDICAL CODING (Expert): The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
- WRITTEN COMMUNICATION (ADVANCED): Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos and documentation. Demonstrates an understanding of effective composition, such as having first line in a paragraph state the subject.
Our professional administrative functions include critical supporting roles in information technology and informatics, finance, administration, legal and community affairs, human resources, communications and marketing, development, facilities, and many more.
At our growing health system, we support each other and encourage excellence among all who are part of our workforce. High-achieving employees stay at Vanderbilt Health for professional growth, appreciation of benefits, and a sense of community and purpose.
Core Accountabilities:
Organizational Impact: Executes job responsibilities with the understanding of how output would affect and impact other areas related to own job area/team with occasional guidance. Problem Solving/ Complexity of work: Analyzes moderately complex problems using technical experience and judgment. Breadth of Knowledge: Has expanded knowledge gained through experience within a professional area. Team Interaction: Provides informal guidance and support to team members.Core Capabilities :
Supporting Colleagues:- Develops Self and Others: Invests time, energy, and enthusiasm in developing self/others to help improve performance e and gain knowledge in new areas.- Builds and Maintains Relationships: Maintains regular contact with key colleagues and stakeholders using formal and informal opportunities to expand and strengthen relationships.- Communicates Effectively: Recognizes group interactions and modifies one's own communication style to suit different situations and audiences. Delivering Excellent Services:- Serves Others with Compassion: Seeks to understand current and future needs of relevant stakeholders and customizes services to better address them.- Solves Complex Problems: Approaches problems from different angles; Identifies new possibilities to interpret opportunities and develop concrete solutions.- Offers Meaningful Advice and Support: Provides ongoing support and coaching in a constructive manner to increase employees' effectiveness. Ensuring High Quality: - Performs Excellent Work: Engages regularly in formal and informal dialogue about quality; directly addresses quality issues promptly.- Ensures Continuous Improvement: Applies various learning experiences by looking beyond symptoms to uncover underlying causes of problems and identifies ways to resolve them. - Fulfills Safety and Regulatory Requirements: Understands all aspects of providing a safe environment and performs routine safety checks to prevent safety hazards from occurring. Managing Resources Effectively: - Demonstrates Accountability: Demonstrates a sense of ownership, focusing on and driving critical issues to closure.- Stewards Organizational Resources: Applies understanding of the departmental work to effectively manage resources for a department/area.- Makes Data Driven Decisions: Demonstrates strong understanding of the information or data to identify and elevate opportunities. Fostering Innovation:- Generates New Ideas: Proactively identifies new ideas/opportunities from multiple sources or methods to improve processes beyond conventional approaches.- Applies Technology: Demonstrates an enthusiasm for learning new technologies, tools, and procedures to address short-term challenges.- Adapts to Change: Views difficult situations and/or problems as opportunities for improvement; actively embraces change instead of emphasizing negative elements.Position Qualifications:
Responsibilities:
Certifications:
Certified Coding Associate - American Health Information Management Association (AHIMA), Certified Coding Specialist - American Health Information Management Association (AHIMA), Certified Coding Specialist - Physician - American Health Information Management Association (AHIMA), Certified Outpatient Coder - American Academy of Professional Coders, Certified Professional Coder - Outpatient - American Academy of Professional Coders, Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA), Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA)Work Experience:
Relevant Work ExperienceExperience Level:
5 yearsEducation:
High School Diploma or GED (Required)Vanderbilt Health is committed to fostering an environment where everyone has the chance to thrive and is committed to the principles of equal opportunity. EOE/Vets/Disabled.
