Full-Time HIM Coder III

The Coder III position is dedicated to either hospital inpatient or hospital outpatient coding. Codes and abstracts clinical information from inpatient or outpatient charts for the purpose of reimbursement, research, and compliance with federal regulations and other agencies utilizing established coding principles and protocols. Inpatient: Identifies, reviews, and assigns complex ICD-10-CM codes, PCS, POA and PSI indicators for inpatient charts. Outpatient: Identifies, reviews, and assigns complex ICD-10-CM codes and CPT for ambulatory surgery and observation charts.

Responsibilities:

• Clarifies complex discrepancies in documentation and coding and assures accurate ICD-10-CM and PCS coding/abstracting assignment for inpatient to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care.
• Clarifies complex discrepancies in documentation and coding and assures accurate ICD-10-CM and CPT coding/abstracting assignment for outpatient surgery to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care.
• Follows up on complex coding of medical records as a result of internal or external reviews which have identified Coding or DRG discrepancies.
• Supports special studies in relation to coding and abstracting information according to policies and procedures.
• Maintains knowledge and skills via written coding resources, clinical information, videos, etc.
• Meets or exceeds productivity and quality standards and established department benchmarks.
• Extracts pertinent information from clinical notes, operative notes, radiology reports, laboratory reports, (including Pathology), procedure records, specialty forms, etc.
• Determines complex code assignment pertinent to diagnostic workups, surgical techniques,
• advanced technology and special services.
• Identifies medical and surgical complications and untoward events for accurate MS-DRG / APR-
• DRG for inpatient charts or APC assignment for outpatient charts.
• Reviews the Medication Administration Report (MAR) in the medical record for medications     
• Hydration, Infusions, and Injections (HII) charged during observation time. Know the resources for the HII hierarchy.
• Responsible for working accounts in the CCF claims processing system.
• Reviews the medical record for Observation cases to perform verification of observation hour and appropriate charges on claims.
• Captures appropriate charges in accordance with CMS billing rules and regulations.
•  Other duties as assigned.

Education:

• High School Diploma is required.

Languages:

• English required.

Certifications:

• Inpatient: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA) or Certified Coding Associate (CCA) by American Health Information Management Association (AHIMA) is required and must be maintained.
• Outpatient: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) by American Health Information Management Association (AHIMA) or Certified Professional Coder (CPC), Certified Outpatient Coder (COC) by American Academy of Professional Coders (AAPC) is required and must be maintained.

Complexity of Work:

• Coding assessment relevant to the work may be required.
• Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.
• Must be able to work in a stressful remote environment and take appropriate action.

Work Experience:

• A minimum of two years of experience abstracting, identifying, reviewing, and assigning complex ICD-10-CM, PCS codes, POA and PSI indicators, surgical complications for inpatient charts or CPT for outpatient charts is required.

Physical Requirements:

• Ability to perform work in a stationary position for extended periods.
• Ability to travel throughout the hospital system.
• Ability to work with physical records, such as retrieving and filing them.
• Ability to operate a computer and other office equipment.
• Ability to communicate and exchange accurate information.
• In some locations, ability to move up to 25 lbs.

Personal Protective Equipment:

• Follows Standard Precautions using personal protective equipment.