Medical Coder

Under the direction of the Coding Manager, functions as a medical coder to review, retrieve, collect, and assign appropriate ICD-10-CM diagnoses codes and ICD-10-PCS or CPT codes for the purposes of compliance with regulations, data and statistical compilation, clinical research, clinical care analysis and optimal reimbursement.

Requirements

• Demonstrates service excellence and patient and family centered care by showing respect, honesty, fairness, and a positive attitude toward all customers.
• Maintains confidentiality.
• Demonstrates dependability, to include attendance and punctuality.
• Is accountable - takes initiative and ownership of issues.
• Displays a professional demeanor. Represents hospital in a positive way. Has a compassionate working relationship with patients and families.
• Assumes personal responsibility for 2-way communication. Communicates and listens effectively with patients, families, coworkers, other departments, physicians/providers, and community.
• Supports coworkers, initiatives and a patient and family centered philosophy; pitches in; does own part and helps others.
• Works to continuously improve work environment/processes (Performance Improvement). Demonstrates a patient and family centered focus when considering/developing improvement solutions.
• Represents willingness/enthusiasm to create, embrace and facilitate change.
• Develops self and others; supports a learning environment; leads by example. Encourages patients and families to give feedback and suggestions for improvement.
• Develops working relationships critical to the organization including patients, families, coworkers, other departments, physicians/providers, and community.
• Encourage others by providing recognition and support.
• Thinks critically; utilizes sound judgment; promptly reports potential risks.
• Maintains state of art knowledge of area of specialty, healthcare trends and practice, and populations served.
• Maintains a level of computer literacy appropriate to their role.
• Meets and maintains current all unit specific and organizational skills/competencies, certifications/licensures, as required.
• Completes hospital-required reviews, e.g., HIPAA, safety, health screening, care concerns, and others as assigned.
• Adheres to National Patient Safety Goals.
• Attends, unless excused, all departmental huddles, in-services, and educational programs to develop new skills and maintain competencies.
• Meets and maintains established productivity and quality standards for a total of 9 out of 12 months within the evaluation period.
• Completes an electronic daily productivity worksheet and submits it by the end of each workday.
• Plans and prioritizes workload at the beginning of shift and throughout shift in accordance with departmental goals for coding turnaround.
• Selects the most accurate DRG for each inpatient account, maintaining compliance based on approved coding guidelines and conventions.
• Reviews entire inpatient electronic health record to accurately code and sequence diagnoses and procedure codes according to "ICD-10 CM/PCS Official Guidelines for Coding and Reporting" and other regulatory guidelines with 95% accuracy or higher.
• Works cooperatively with the medical staff and other healthcare professionals in obtaining documentation to complete medical records and ensure optimal and accurate coding. Communicates effectively with medical staff through use of electronic queries per established departmental policy.
• Reviews entire ambulatory surgery, observation, or outpatient electronic health record to accurately code and sequence diagnosis codes according to "ICD-10-CM Official Guidelines for Coding and Reporting" and to support medical necessity with 95% accuracy or higher.
• Assigns appropriate first-listed and secondary CPT/HCPCS and modifiers for outpatient procedures according to CPT and OCE/NCCI coding guidelines with 95% accuracy or higher.
• Reviews medication administration records and accurately posts infusion administration charges for observation, outpatient oncology and infusion service accounts.
• Reviews interventional cardiology procedure logs and documentation to verify, correct and update procedure or charge codes to ensure accurate coding and charging of procedures, devices, implants, and supplies.
• Abstracts patient data, including discharge status, consulting providers, admitting, and attending provider, and surgeon from electronic health record to appropriately complete Epic ADT Information screen prior to completing an account for billing and claims submission for inpatient, ambulatory surgery, or outpatient visit account with 95% accuracy.
• Reviews professional journals, newsletters, and educational assignments in a timely fashion to keep up to date on current coding guidelines.

Benefits

• Health insurance
• Retirement plan
• Paid time off
• Holiday pay