Inpatient Coder 3 Certified / HIM Coding

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Position Summary

Reviews inpatient clinical documentation to determine the appropriate assignment of alpha numeric diagnosis/procedure codes and Medicare Severity Diagnosis Related Groups (MS-DRG).  Data is classified for internal and external statistical reporting, research, regulatory compliance and reimbursement.

Codes high dollar and all types of multifaceted accounts which includes, but is not limited to, interventional radiology, interventional cardiology, cardiovascular surgeries, major transplants, neurovascular surgeries, spinal fusions and coding level 1 trauma (multi significant)

Position Responsibilities

Key Areas of Responsibility

Coding

1.      Applies strong knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to determine the appropriate assignment of diagnosis and procedure codes for more complex accounts.

2.      Analyzes medical records using the Uniform Hospital Discharge Data Set (UHDDS), interprets documentation and assigns proper International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnoses and ICD-10-Procedural Classification System (PCS) operative procedure codes utilizing designated software to included Computer Assisted Coding (CAC) and/or encoder, coding manuals and other reference material.

3.      Reviews DRG assigned to each record. Enters coded/abstracted information into software, analyzes DRG groupings, and observes for appropriate DRG assignment.

4.      Reviews high dollar and more complex cases including but not limited to, medical, surgical, behavioral health and IP Rehabilitation.

5.      Applies IRF-PAI guidelines for IP Rehabilitation coding.

6.      Adheres to all department coding procedures, policies, guidelines and quality standards.

7.      Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association/American Association of Procedural Coders and adheres to official coding guidelines.

8.      Meets revenue cycle goals (Key Performance Indicators (KPIs) and Productivity Standards).

Issue Resolution

1.      Complete on a daily basis cases that have been assigned for review of edits, etc.

Communication

1.      Collaborates with clinical documentation specialists (CDS) to determine appropriate DRG assignment for compliance and reimbursement purposes.

2.      Collaborates with Quality Management and other departments (Billing Registration, etc.) as required.

3.      Seeks clarification from attending physician in cases where documentation is absent, ambiguous, or contradictory.

Training

1.      Assists in training and mentoring new coders to become acclimated to new environment, and understand internal coding policies and procedures

Working Relationships

This position reports to Inpatient Coding Manager

Education

·        Associate’s Degree or equivalent experience

Experience

·        Minimum: Two to three years of progressive on-the-job experience in an acute care hospital.

·        Preferred: Two to four years of progressive on-the-job experience in an acute hospital.

Licensure, Certification, Registration

·        Certified Coding Specialist (CCS) required and maintained thereafter.

Language Skills

·        Strong written and verbal communication skills.

Knowledge, Skills and Ability Requirements

Strong knowledge of:

·        ICD‑10-CM diagnostic and ICD-10-PCS procedure codes

·        UHDDS

·        Various DRG methodologies (MS-DRG, APR-DRG, Tricare, etc.)

·        IP Rehabilitation coding rules for IRF-PAI

·        Clinical information related to areas of responsibility

·        Microsoft Office Products; Word, Excel

·        Encoder and/or CAC

Skills:

·        Read, write and speak English proficiently.

·        Strong analytical capabilities.

·        Strong organizational skills.

·        Proficiently read and interpret physician writing.

Strong ability to:

·        Function independently.

·        Handle multiple priorities.

·        Listen and acknowledge ideas and expressions of others attentively.

·        Converse clearly using appropriate verbal and body language.

·        Collaborate with others to achieve a common goal through mutual cooperation.

·        Influence others for positive and productive outcomes

·        Work across the Hartford HealthCare System.

We take great care of careers.

With locations around the state, Hartford HealthCare offers exciting opportunities for career development and growth. Here, you are part of an organization on the cutting edge – helping to bring new technologies, breakthrough treatments and community education to countless men, women and children. We know that a thriving organization starts with thriving employees-- we provide a competitive benefits program designed to ensure work/life balance. Every moment matters. And this is your moment.