A Brief Overview Responsible for accurately and timely coding of inpatient medical records following established coding, CMS regulations and hospital guidelines. Accurately codes diagnostic and procedural information following coding guidelines and regulations information including, facility specific guidelines and federal regulations.
Reviews low to moderate complex medical records to assign diagnostic ICD-10-CM and or ICD-10-PCS codes according to established coding, CMS, and hospital guidelines (95%) Coding Technical Skills- ICD-10-CM, ICD-10-PCS, MS-DRG's, APR DRGs, ROM, SOI, and POA assignment. Understanding of CC's, MCC's, HCC's, impact on quality reporting, HAC's and PSI's Maintains productivity and quality rate according to established standards.
Works within UH billing time frames. Maintains coding knowledge and skills via written coding resources, clinical information and educational webinars. Maintains knowledge of guidelines and regulations affecting the UHHS Coding Department.
Maintains up to date credentials. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA). Abstracts selected data items and enters in 3M encoder/Epic software with accuracy and attention to detail.
Follows facility query policy and CDI reconciliation process. Utilizes critical thinking/problem solving processes. Collaborates with and supports the Clinical Documentation Integrity Team.
Demonstrates effective time management skills by completing assignments within time constraints and calendar schedule. Additional Responsibilities Participates in educational and informational activities. Performs other duties as assigned.
Complies with all policies and standards. For specific duties and responsibilities, refer to documentation provided by the department during orientation. Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients.
Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace. Education Associate's Degree preferably in HIM (Required) Bachelor's Degree (Preferred) Work Experience 1+ years Of ICD-10-CM and ICD-10-PCS coding experience (Preferred) Knowledge, Skills, & Abilities Medical terminology, anatomy/physiology, pathophysiology and pharmacology knowledge.
(Required proficiency) Detail-oriented and organized, have excellent time-management skills, and have good analytical and problem solving ability. (Required proficiency) Notable client service, communication, presentation and relationship building skills. (Required proficiency) Ability to function independently and as a team player in a fast-paced, demanding work environment.
(Required proficiency) Must have strong written and verbal communication skills. (Required proficiency) Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.). Must be able to proficiently work within with multiple systems.
(Required proficiency) Licenses and Certifications Certified Professional Coder (CPC) (Required Upon Hire) or Certified Coding Specialist (CCS) (Required Upon Hire) or Registered Health Information Technologist (RHIT) (Required Upon Hire) or Registered Health Information Administration (RHIA) (Required Upon Hire) or Certified Inpatient Coder (CIC) (Required Upon Hire) Physical Demands Standing Occasionally Walking Occasionally Sitting Constantly Lifting Rarely up to 20 lbs Carrying Rarely up to 20 lbs Pushing Rarely up to 20 lbs Pulling Rarely up to 20 lbs Climbing Rarely up to 20 lbs Balancing Rarely Stooping Rarely Kneeling Rarely Crouching Rarely Crawling Rarely Reaching Rarely Handling Occasionally Grasping Occasionally Feeling Rarely Talking Constantly Hearing Constantly Repetitive Motions Frequently Eye/Hand/Foot Coordination Frequently