Coder III, HIM - HIM Financial Non-Exempt; Non-Union

Essential Duties

• Inpatient coding of all diagnostic and procedural information from the medical records using ICD-10-CM, ICD-10-PCS, and CPT/HCPCS, and Modifier classification systems and abstracting patient information as established and required by official coding laws, regulations, rules, guidelines, and conventions.
• Reviews the entire medical record; accurately classify and sequence diagnoses and procedures; ensure the capture of all documented conditions that coexist at the time of the encounter/visit, all medical necessity diagnoses, complications, co-morbidities, historical condition or family history that has an impact on current care or influences treatment, and all external causes of morbidity.
• Enter patient information into inpatient and outpatient medical record databases (Clin Trac/HDM). Ensures accuracy and integrity of medical record abstracted UB-04 & OSHPD data elements prior to billing interface and claims submission.
• Works cooperatively with HIM Coding Support and/or Clinical Documentation Improvement Specialist in obtaining documentation to complete medical records and ensure optimal and accurate assignment of diagnosis & procedure codes.
• Assists in the correction of regulatory reports, such as OSHPD data, as requested.
• Attendance, punctuality, and professionalism in all HIM Coding and work related activities.
• Consistently assumes responsibility and displays reliability for completion of tasks, duties, communications and actions. Completes tasks accurately, legibly, and in a timely fashion.
• Performs other duties as requested/assigned by Director, Manager, Supervisor, or designee.
• Ability to achieve a minimum of 95% coding accuracy rate as determined by any internal or external review of coding and/or department quality review(s).
• Ability to achieve a minimum of 95% abstracting accuracy rate of UB-04 and OSHPD data elements as determined by any internal or external review of coding and/or department quality review(s).
• Assist in ensuring that all medical records contain information necessary for optimal and accurate coding and abstracting.
• Recognizes education needs of based on monthly reviews and conducts self-improvement activities.
• Ability to act as a resource to coding and hospital staff on coding issues and questions.
• Ability to improve MS-DRG assignments specific to the documentation & coding of PDx, Sec Dx, CC/MCC, PPx, and Sec Px in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Ability to improve APR-DRG, SOI, and ROM assignments specific to the documentation & coding of PDx, Sec Dx, CC/MCC, PPx, and Sec Px in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Ability to improve APC/HCC assignments specific to medical necessity documentation & coding of PDx, Sec Dx, and CPT/HCPCS in accordance with official coding laws, regulations, rules, guidelines, and conventions.
• Maintains at minimum, expected productivity standards (See HIM Practice Guidelines) and strives to maintain a steady level of productivity and provides consistent effort.
• Works coding queues/task lists to ensure 95% of patient bills are dropped within 5 days after patient discharge/date of service.
• Works coding queues/task lists to ensures the remaining 5% of patient bills are dropped within 2 weeks of discharge/date of service.
• Assist other coders in performance of duties including answering questions and providing guidance, as necessary.
• Assists Patient Financial Services (PFS), Patient Access, and other departments in addressing coding issues/questions and/or providing information so that an interim bill can be generated. Assists with physicians, physician office staff and hospital ancillary department staff with diagnostic or procedural coding issues/questions, as needed.
• Assists in the monitoring unbilled accounts to ensure that the oldest records are coded and/or given priority.
• Maintains AHIMA and or AAPC coding credential(s) specified in the job description.
• Attend coding & CDI seminars, webinars, and in-services to maintain the required annual continued education units (CEU).
• Keep up-to-date and reviews ICD-10 Official Guidelines for Coding & Reporting, AHA Coding Clinic, and CPT Assistant to maintain knowledge of the principles of coding.
• Keep up-to-date and reviews other professional journals and newsletters in a timely fashion to maintain knowledge of the principles of coding.
• Consistently attend and actively participate in the daily huddles.
• Consistently adhere to HIM policies and procedures as directed by HIM management.
• Demonstrates an understanding of policies and procedures and priorities, seeking clarification as needed.
• Participates in continuously assessing and improving departmental performance.
• Ability to communicate changes to improve processes to the director, as needed.
• Assists in department and section quality improvement activities and processes (i.e. Performance Improvement).
• Works and communicates in a positive manner with management and…