Medical Records Coding Specialist II
2 weeks ago
Position Title: HIM Coding Specialist II - Full Time
Work Schedule: Days, 8:00 AM - 4:30 PM
Patient Demographics:
The role encompasses serving a diverse patient demographic, including geriatric, adult, adolescent, pediatric, and newborn populations, as well as interactions with facility staff, physicians, visitors, vendors, and the general public.
Position Summary:
Under the guidance of the Director of Health Information Management (HIM), the HIM Coding Specialist II is responsible for executing intricate tasks related to the review, abstraction, coding, and risk assessment of both inpatient and outpatient medical records. This is essential for statistical, administrative, billing, and risk management purposes.
The specialist must be available for scheduled working hours, including holidays, call-backs, evenings, weekends, and on-call duties. Participation in emergencies and community disasters is expected as part of the role.
It is crucial for the employee to recognize their responsibility to report any perceived misconduct, including potential violations of laws, regulations, policies, or the organization's standards of conduct.
The incumbent must thrive under pressure, manage multiple deadlines, and consistently demonstrate cooperative behavior with colleagues and supervisors.
Qualifications:
To excel in this position, candidates should possess a high school diploma or equivalent. Preferred qualifications include:
- Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) and/or CCS-P or Certified Professional Coder (CPC), or equivalent certification.
- A minimum of two years of coding experience in an acute care environment utilizing ICD-9-CM and CPT/DRG coding systems.
- Familiarity with ICD-10-CM coding principles applicable to both acute care and skilled nursing facilities.
- Understanding of the prospective payment system and its impact on reimbursement.
- Proficiency in medical terminology, anatomy, and physiology.
Candidates should also demonstrate strong data entry skills, typing at a rate of 40-50 words per minute, and possess basic knowledge of commonly used business software, including Microsoft Office applications.
Licensure/Certifications:
To be successful in this role, candidates should hold relevant certifications such as RHIT, CCS, or CPC, along with a minimum of two years of coding experience in an acute care setting.
Key Responsibilities:
- Analyze and interpret patient medical records to determine billable services and assign appropriate diagnostic/procedure codes in compliance with governmental and third-party payer requirements.
- Perform data entry into online medical record systems and verify the accuracy of imported data.
- Identify and document the Present on Admission (POA) indicators for diagnoses to track adverse outcomes.
- Monitor billing performance to ensure optimal reimbursement while adhering to compliance regulations.
- Stay updated with coding regulations and reimbursement practices to enhance revenue cycle management.
- Maintain a list of accounts pending coding and ensure timely processing.
- Achieve quality standards with a minimum of 95.5% accuracy in coding principal diagnoses and procedures.
- Maintain a monthly productivity rate of 95.5%.
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