Hospital Certified Senior Coder

3 days ago


New Brunswick, United States Saint Peter's Healthcare System Full time
Hospital Certified Senior Coder at Saint Peter's Healthcare System summary:

The Hospital Certified Senior Coder is responsible for coding and abstracting patient records, managing daily workflows, and ensuring accurate coding for diagnoses and procedures. This role involves collaborating with clinical documentation specialists, training newly hired coders, and participating in hospital performance improvement initiatives. Five years of inpatient coding experience and strong decision-making skills are required for successful performance in this role, which is conducted remotely with in-hospital experience necessary.

Hospital Certified Senior Coder
Clinical Document-Coding Mgmt

The Hospital Certified Senior Coder will:

CODING:
  • Utilizing judgment gained from coding experience, assign appropriate codes for all applicable diagnosis and procedures, concurrently on patient units.
  • Code and abstract.
  • Independently manage daily workflow on assigned unit(s).
  • Validate correct patient types (observation vs. inpatient) by checking physician order.
  • Reconcile HIM discharged not final billed report (DNFB) to ensure all discharged charts are accounted for on his/her assigned units.
  • Notify coding supervisor, director, clinical documentation; assistant manager HIM; nursing manager, and clinical documentation specialist covering unit regarding missing patient records.
  • On discharge reconcile with clinical documentation specialist nurse, finalize coding, abstract, accept final DRG for billing.
  • Deliver discharged charts to the Health Information Management Department.
  • Complete concurrent admission reviews within 48 hours of patient admission (excluding weekend and holidays).
  • Ensure timely follow-up reviews in accordance with unit review guidelines.
  • Collaborate with clinical documentation nursing specialists by identifying conflicting, ambiguous, or incomplete information in the medical record.
  • Participate in hospital performance improvement activities as requested.
  • Ensure that hospital acquired conditions (HAC), and complications are validated by clinical documentation nursing specialists, and/or performance improvement department.
  • Query physicians for all questions relating to diagnostic and procedural information in the medical record.
  • Notify coding supervisor all issues that will delay billing.

MENTORING and TRAINING: Under the direction of the Director and/or coding supervisor, Clinical Documentation & Coding Management:
  • Assist with training of newly hired coders to include, but not limited to CPT, HCPCS and/or ICD coding.
  • Train fellow coders on use of computer systems including, but not limited to, McKesson STAR and 3M.
  • Respond to questions and assists fellow coders with code assignments as needed.


Requirements:
  • Knowledge of coding systems, medical terminology, anatomy and physiology required.
  • A minimum of five (5) years of inpatient coding experience required.
  • Strong interpersonal and decision-making skills required.


Remote

In-Hospital Experience Required

Grade 123
Keywords:

hospital coding, medical coding, health information management, CPT coding, ICD coding, HCPCS, clinical documentation, medical records, healthcare, coding mentor



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