Under the direct supervision of the Director or Manager, the Coder 3 is responsible for coding all diagnoses and procedures using current ICD-9-CM, and/or ICD-10-CM, ICD-10-PCS and CPT/HCPCS coding systems in compliance with Uniform Hospital Discharge Data Set (UHDDS) guidelines, ICD-9-CM/ICD-10-CM coding conventions, federal and state regulations. The hospital services that are coded in this position may include acute inpatient (including Obstetric and Newborn), Physical Rehabilitation, Behavioral Health, Same Day Surgery, Interventional Radiology, Emergency Department records and Outpatient Ancillary. The Coder 3 is also responsible for abstracting the required data elements for accurate data collection, reporting, and billing.
Major Position Responsibilities:
- Codes records of discharged patients using the current ICD-9-CM, and/or ICD-10-CM, ICD-10-PCS and CPT/HCPCS coding system guidelines in accordance with regulatory compliance and quality monitoring criteria and actively participates in transition to ICD-10-CM and ICD-10-PCS.
- Adheres to the AHIMA Standards of Ethical Coding developed by the AHIMA Council on Coding and Classification.
- Queries the physicians as needed to obtain clarification of chart documentation to accurately assign codes to reflect the patient’s diagnoses and procedures performed and maintains supporting documentation obtained.
- Abstracts data from the medical record document according to data collection, reporting, and billing requirements in compliance with quality monitoring criteria.
- Verifies that patient abstracts have been completed for all the required patient hospital services monthly for data retrieval, hospital Case Mix reporting, and billing of the outstanding account receivables (delinquent data).
- Efficiently utilizes the Medical Centers’ medical record abstract, encoder, patient index, and other computerized department products that are used in the performance of all assigned duties.
- Responsible for on-going education to maintain current professional certification. Responsible for the review and comprehension of current information regarding coding and compliance issues.
- Performs other related duties as requested by Management.
Safety and Infection Control Responsibilities
- Responsible to maintain a safe and clean work environment, including unit based specific safety and infection control requirements.
Qualifications: ESSENTIAL COMPETENCIES, KNOWLEDGE, & EXPERIENCE
- Two (2) years current acute care/hospital coding experience, required.
- Internal transfers: will consider one year Coder 1 or Coder 2 experience at Tri-City Medical Center in lieu of two years current acute care/hospital coding experience.
- Intermediate computer skill, required.
- Knowledge of medical terminology, anatomy, physiology, pathophysiology, coding compliance and reimbursement guidelines.
- Successful completion of skills assessment with a score of at least 80% that evaluates application of candidate’s knowledge.
- Detail oriented with strong analytical skills, required.
- Ability to demonstrate flexibility in response to unexpected change in work volume and work schedule, required.
- Excellent human relations skills including listening, conflict resolution, and team building, required.
- High school diploma or GED, required.
Requires 1 of the following:
- Current Registered Health Information Administrator (RHIA)
- Current Registered Health Information Technician (RHIT)
- Current Certified Coding Specialist (CCS)
- Current Certified Inpatient Coder (CIC)
Each new hire candidate who is offered employment must pass a physical evaluation, urine drug screen and pre-employment background checks before starting work.