HIM Coder 2
4 weeks ago
Job Summary
Under the general supervision of Manager and direct supervision of Supervisor, following established policies, procedures and professional guidelines, the Coder 2 will: Perform a thorough review of medical record documentation to accurately assign diagnosis and procedure codes. Utilize the encoder system to sequence the codes assigned and calculate the corresponding MS-DRG/APR DRG/APC grouper. Abstract patient information into the computerized medical record and billing systems, ensuring the accuracy and integrity of the medical record data abstracted and encounter information prior to finalizing the encounter. Collaborate with the Clinical Documentation Improvement Team, Coding Team Coordinators and/or Supervisor to query for clarification of ambiguous documentation or, patient diagnostic and procedural information in the medical record. Be knowledgeable in the requirements of the industry with regard to Medicare and/or Managed care regulations, the International Classification of Diseases (ICD-9 and ICD-10-CM/PCS) and the Current Procedural Terminology (CPT) coding systems. Maintain quality and productivity standards established for the department and demonstrate proficiency in coding all types of moderate to high-complexity inpatient and outpatient records.The Coder 2 may provide guidance and assistance to Coder I staff, Apprentices and clinical practice students orienting to the department. The Coder 2 is responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital.
Essential Functions:
Reviewing medical records and assigning diagnostic and procedural codes using ICD-9-CM/ICD-10 CM/PCS and CPT/HCPCS and any other designated coding classification system in accordance with coding guidelines. Assigning and sequencing codes accurately based on medical record documentation. Assigning the appropriate discharge disposition. Abstracting and entering coded data for hospital statistical and reporting requirements Communicating documentation improvement opportunities and coding issues to appropriate personnel for follow up and resolution Adhering to accuracy and productivity levels established by the department Communicating with co-workers, management, and hospital staff regarding clinical and reimbursement issues Adhering to the American Health Information Management Association’s code of ethics and departmental Code of Integrity Maintain coding credential along with any required CEUs for ongoing credential maintenance and subject matter expertise.
Qualifications
Required:
Possession of a national certification in health information management coding from the American Health Information Management Association (AHIMA), as a Certified Coding Specialist (CCS). Advanced-level knowledge of guidelines for the sequencing of diagnosis and procedure codes for appropriate classification systems. Advanced-level knowledge of anatomy, physiology, pathophysiology, pharmacology, and medical terminology to accurately translate medical record documentation into the appropriate classification system for reporting purposes. Experience in computerized encoding and abstracting software. Excellent professional verbal and written communication skills. At least two years of coding experience in an acute care setting, preferably a Trauma 1 teaching hospital or large healthcare delivery system. Ability to multi-task and work independently. Ability to efficiently complete work assignments and interact with coding leadership team to review and discuss documentation, coding and reimbursement issues.Preferred:
Possession of a national certification in health information management coding from the American Health Information Management Association (AHIMA), as a Certified Coding Specialist (CCS) plus RHIT or RHIA certification. Experience with Epic electronic medical record software and 3M encoding and abstracting software. Five years of coding experience in an acute care setting, preferably a Trauma 1 teaching hospital or large healthcare delivery system.-
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