Inpatient Coder 1

Miami, FL | Full-Time Health Information Management

Summary

HIM Inpatient Coder 1 is responsible for reviewing the clinical documentation contained in the in-patient health records to accurately assign and sequence ICD-9 diagnostic and ICD-9 procedure codes to inpatient records for use in reimbursement and data collection.

Responsibilities

• Has the knowledge and experience to code In-patient medical records using ICD-9 and/or ICD-10 code set.
• Ensures all accounts are coded correctly, which will provide an accurate MS-DRG or APR-DRG for appropriate reimbursement.
• Ensures all accounts are coded within 4 days of the patient's discharge date, meeting productivity standards according to AHIMA Guidelines depending on record type.
• Verifies patient information to identify any discrepancies and ensures that all codes and any other abstracted information is applied to the appropriate patient's encounter.
• While reviewing the record for coding purposes, serves as a quality reviewer, and identifies any documents not belonging to the patient, or the correct patient's encounter.
• Ensures the accuracy when using the appropriate modifiers while coding out patient's encounters.
• Assesses documentation and if necessary queries the physician for additional information when indicated to clarify a diagnosis, symptom or any reason for services provided, according to Coding Guidelines and Coding Clinics.
• Makes sure all codes are utilized to reflect the care rendered to the patient which in return will ensure patient safety, accuracy of data retrieval and provides the organization with accurate reimbursement for the care provided to the patient.
• Recognizes and reports unusual circumstances and/or information with possible risk factors to the Coding Associate Administrator or the Coding Director.
• Meets continuing education requirements established by American Health Information Management Association (AHIMA) and/or American Association of Professional Coders (AAPC) to maintain appropriate certification and competency in job skills and knowledge.
• Is actively involved in all ICD-10-CM-PCS education sessions provided by JHS, and any other outside entity approved by JHS.
• Shows competency according to education received.
• Adheres to the Standards of Excellence at all times, and respects the rights, privacy and property of others at all times including the confidentiality of information, according to Administrative Policies HIPAA Guidelines and all applicable laws and regulations.
• Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise).
• Performs other related duties as assigned.

Experience

Generally requires 0 to 3 years of related experience.

Education

High School diploma is required.

Skill

• Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines.
• Ability to communicate effectively in both oral and written form. Ability to handle difficult and stressful situations with critical thinking and professional composure.
• Ability to understand and follow instructions.
• Ability to exercise sound and independent judgment.
• Knowledge and skill in use of job appropriate technology and software applications.

Credentials

Employee hired AFTER June, 2015 must be credentialed with an HIM/Coding Credentials and/or Certification by AHIMA or AAPC.

Unit Specific Credential

Working Conditions

Physical Requirements - Job function is sedentary in nature and requires sitting for extended periods of time. Function may require frequent standing or walking. Must be able to lift or carry objects weighing up to 20 pounds. Jobs in this group are required to have close visual acuity to perform activities such as: extended use of computers, preparing and analyzing data and analytics, and other components of a typical office environment. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).

Environmental Conditions - Jobs in this group are required to function in a fast paced environment with occasional high pressure or emergent and stressful situations. Frequent interaction with a diverse population including team members, providers, patients, insurance companies and other members of the public. Function is subject to inside environmental conditions, with occasional outdoor exposures. Possible exposure to various environments such as: communicable diseases, toxic substances, medicinal preparations and other conditions common to a hospital and medical office environment. May wear Personal Protective Equipment (PPE) such as gloves or a mask when exposed to hospital environment outside of office. Reasonable accommodations can be made to enable people with disabilities to perform the described essential functions. Additional information and provision requests for reasonable accommodation will be provided by the home unit/department in collaboration with the Reasonable Accommodations Committee (RAC).