HIM Inpatient Coding Specialist III

Responsibilities:

• Examines the complete medical record to accurately determine the principal & secondary diagnoses, procedures, co-morbidities and complications demonstrating 96% accuracy as determined by audits.
• Sequence the diagnoses & procedures to obtain the optimal DRG or APR-DRG assignment and demonstrates 96% accuracy as determined by monthly audits.
• Simultaneously abstracts and enters all coded information into the Pennchart/EPIC system for timely billing. This includes the correct discharge disposition verified through the Case Management Department Consistently codes the oldest cases first and prioritizes high dollar cases over 4 days old first.
• Demonstrates a consistent level of performance; strives to maintain a steady level of productivity according to the following guidelines:
• • HUP: Average of 15 inpatient records coded daily
  • PPMC: Average of 15 inpatient records coded daily
  • PAH: Average of 19 inpatient med/surg charts or 22.5 OB/NB inpatient records coded daily
• Refers charts that require clarification of vague or unclear documentation for accurate coding and DRG assignment to a Coding Quality Specialist to query the physician for the needed documentation.
• Promptly and accurately assigns Coding Hold reasons to all records that cannot be completed immediately due to:
• • Missing Operative Notes
  • Missing Pathology Report
  • Physician Query Needed
  • Death Review
  • Discharge Disposition
  • Missing Other Reports (Card Cath, EPS, etc)
• Is willing to adjust schedule to complete workload and meet pivotal revenue cycle deadlines when requested by management. Cooperates with departmental work volumes by adjusting work schedule.
• Correctly identifies and applies Present on Admission indicators to all applicable diagnoses according to designated guidelines. Accuracy is important due to the far-reaching impact on reimbursement and quality metrics.

• Consistently codes the oldest cases first and prioritizes high dollar cases over 4 days old first.

• Strives to become fluent in the inpatient coding at all of the UPHS facilities.

• Performs revenue cycle/DNFB activities as needed.

• Reviews and processes provider queries.
• Assigns high dollar and death charts to the coding staff in an equitable manner.
• Performs inpatient SMART reviews.
• Assists the Coding Manager with other duties as assigned.
• Responsible for continuing education both inside and outside the organization along with tracking continuing education credits to maintain professional credentials.
  

Credentials:

• Certified Coding Specialist (Required).
• RHIA or RHIT (Preferred).

Education or Equivalent Experience:

• H.S. Diploma/GED (Required).
• 2+ years of work experience coding at an inpatient academic medical center (Required).
• Bachelor of Arts or Science in Health Information or Related field (Preferred).

Skills & Abilities:

• Extensive knowledge of medical terminology, human anatomy and physiology, and clinical disease processes.
• Extensive knowledge of ICD-9-CM and CPT-4 classification systems.
• Ability to assess, prioritize and complete multiple tasks in a stressful environment.