HIM Inpatient Coding Spec I - REMOTE

HIM Inpatient Coding Specialist Level I

Performs all coding and abstracting by reviewing medical records and selecting the principal diagnosis, secondary diagnoses, principal procedure, and secondary procedures accurately. Performs analysis of the DRG assigned to produce the highest level of reimbursement to which the facility is legally entitled according to stringent coding and compliance guidelines.

Accountabilities

• Examines the complete medical record to accurately determine the principal & secondary diagnoses, procedures, co-morbidities and complications demonstrating 95% accuracy as determined by audits.

• Sequences the diagnoses & procedures to obtain the optimal DRG or APR-DRG assignment and demonstrates 95% accuracy as determined by monthly audits.

• Simultaneously abstracts and enters all coded information into EPIC for timely billing. This includes the correct discharge disposition verified through the CRM notes available in PennChart.

• Demonstrates a consistent level of performance; strives to maintain a steady level of productivity according to the following guidelines:

HUP

· Average of 7.5-11.5 inpatient records coded daily

PPMC

· Average of 7.5-11.5 inpatient records coded daily

PAH

· Average of 15 inpatient med/surg charts 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)

• 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.

• 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.

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

• Responsible for continuing education both inside and outside the organization along with tracking Continuing Education credits to maintain professional credentials.

• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures

• Other duties as assigned to support the unit, department, entity, and health system organization

 Minimum Requirements

Required Education and Experience

• H.S. Diploma/GED is required.

• Previous work experience or training in coding inpatient medical records is required.

• Bachelor's Degree Health Information Management or a related field is preferred.

Licenses, Registrations, and Certifications

• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) is preferred.

• Certified Coding Specialist (CCS) is preferred.

Required Skills and Abilities

• Extensive knowledge of medical terminology, human anatomy and physiology, and clinical disease processes

• Extensive knowledge of ICD-10-CM and ICD-10-PCS

• Ability to assess, prioritize and complete multiple tasks in a stressful environment

• Familiarity with computerized encoders

As part of our COVID-19 response, this position may currently be offering partial or full remote work. However, in the near future this position will require full or partial on-site work.

Be a part of the exciting and ground-breaking upcoming years for the Penn Medicine Information Services department!

Because growth is essential to continuing to meet the current and future needs of patients, Penn Medicine continues to expand its capabilities.

Penn Medicine's Information Services (IS) Department focuses its efforts on the clinical and financial systems that support the day-to-day operations of six (6) hospitals, several satellite practices, and more than 8,923 physicians.

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