Coder Inpatient - REMOTE

Advocate Aurora Health | Remote
remote health health information management information management management medical team soi mortality rom drg safety icd-10-cm
Major Responsibilities:

Assigns and sequences codes for the inpatient record using ICD-10-CM and PCS codes as defined in the Uniform Hospital Discharge Data Set (UHDDS), based on the American Health Information Management Association (AHIMA) and organization specific guidelines for reimbursement, statistical purposes, core measure reviews, and data collection.

Coder reviews all documentation form Qualified Medical Providers (QMPs) to assign all significant diagnoses. Additionally, all documentation from nurses must be reviewed to assign correct codes. Ensure all documentation reviewed supports diagnosis in the health information record so all significant diagnoses and procedures are captured correctly for reimbursement, statistical research, Severity of Illness (SOI) and Risk of Mortality (ROM), best Diagnostic Related Group (DRG) outcome, and accurate assignment of present on admission (POA) indicators.

Must be able to do clear and concise query to the physician when there is conflicting documentation in the medical record. Must be able to identify and place accounts to the correct status/hold when additional documentation is required for accurate and complete coding.

Collaborate with Clinical Documentation Specialist (CDS) team as part of the clinical documentation validation, to provide the most accurate and complete diagnoses. Work with CDS team to validate the DRG, SOI/ROM, and Hierarchical Condition Category (HCC). Forward queries created by the CDS Team to obtain the most accurate DRG. This provides outcomes for the organization as well as accurate reimbursement for benchmarking.

Collaborate with the Coding Quality Team when alerted to coding quality issues found via internal or external reviews; implement with accuracy coding quality recommendations.

Work with HIM operations as needed to clarify queries and documentation needs for the completion of the medical record. Verify accurate abstracting of discharge disposition.

Collaborates with Quality and CDS to ascertain that charts are at the highest level possible for SOI/ROM, especially in mortality cases for benchmarking purposes based on documentation. Query for unclear or conflicting documentation

Maintains a productivity rate of 100% or more on a monthly basis and a quality rate of 95%.

Promotes patient safety by reporting of issues through established channels and participating in safety initiatives.

Safeguards confidential and privileged patient information.

Licensure, Registration, and/or Certification Required:

Coding Specialist (CCS) certification issued by the American Health Information Management Association (AHIMA), or

Health Information Technician (RHIT) registration issued by the American Health Information Management Association (AHIMA), or

Health Information Administrator (RHIA) registration issued by the American Health Information Management Association (AHIMA), or

Education Required:

Associate's Degree in Health Information Management or related field.

Experience Required:

Typically requires 5 years of experience in inpatient and Day Surgery/Observation coding and proven competency in Day Surgery/Observation coding with progressive inpatient coding experience in an integrated acute care teaching setting.

Knowledge, Skills & Abilities Required:

Proficient in Microsoft Office, Word, Excel, and PowerPoint.

Advanced knowledge and understanding of anatomy, physiology, medical terminology, pathophysiology (disease process, surgical terminology and pharmacology) and is able to apply these sciences to accurately assign codes to cases.

Demonstrates knowledge of National Council on Compensation Insurance, Inc (NCCI) edits, and local and national coverage decisions.

Expert knowledge and experience in ICD-10-CM and PCS coding system and 3M Encoder.

Extensive knowledge with Quality Outcomes, Agency for Healthcare Research and Quality, including Patient Safety Indictors, Hospital Acquired Conditions, and mortality.

Advanced knowledge of pharmacology indications for drug usage and related adverse reactions.

Expert knowledge of coding workflow and optimization of technology including how to navigate in the electronic health information record and in health information management and billing systems.

Excellent communication and reading comprehension skills.

Demonstrated analytical aptitude, with a high attention to detail and accuracy.

Experienced with remote workforce operations required.

Strong sense of ethics.

Physical Requirements and Working Conditions:

Exposed to a normal office environment.

Must be able to sit majority of the workday and lift, bend, and stretch throughout the workday.

Must be able to lift up to 15 lbs. occasionally.

Must have functional vision.

Position requires repetitive use of hands; therefore, must have excellent fine manipulation skills.

Position requires travel to other sites; therefore, may be exposed to road and weather hazards.

Operates all equipment necessary to perform the job.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

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