Certified Coder

Certified Coder

The Certified Coder is accountable for conversion of diagnoses and treatment procedure into codes using an international classification of diseases. Requires skill in the sequencing of diagnoses/procedures to optimize reimbursement. Ensures that records are coded in an accurate and timely manner.

Standards of Behavior

William Newton Hospital's Standards of Behavior allow a mechanism for holding each employee accountable and encourages us to "raise the bar".

All employees are expected to familiarize themselves with the Standards and practice them daily.

Integrity: We act with unwavering moral principle, transparency, and sincerity in every interaction.

Patient-Centered: We meet patients where they are, ensuring they are active participants in their care journey. We prioritize the patient's physical and emotional well-being over all else.

Accountability: We own our actions. We set clear expectations and hold all team members to the same high standards.

Compassion: We treat every patient, family member, and colleague with kindness, empathy, and dignity.

Excellence: We approach every task, large or small, with enthusiasm. We continually pursue mastery and best practices in our field.

Duties and Responsibilities:

• Reviews chart thoroughly to ascertain all diagnoses/procedures.
• Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on chart or clarification of documentation is needed.
• Ensures diagnoses and procedures on coding summary are supported by the physician's documentation.
• Ensures that codes are assigned correctly and sequenced appropriately as per coding guidelines and government regulations.
• Refers chart to Director/Coding Supervisor, if there is a question regarding the diagnoses/codes.
• Utilizes computerized coding/abstracting equipment.
• Codes all diagnoses/procedures in accordance to ICD 10-CM/PCS coding principles, guidelines, and government regulations.
• Meets quality standards of having 95% accuracy of principal diagnoses and procedures appropriately and/or correctly coded.
• Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.
• Acts as a resource person to Hospital staff for coding and HIM issues.
• Must be familiar with all charting and coding requirements.
• Demonstrate knowledge of computer system.
• Willingly accepts additional assignments.

Requirements:

• Adheres to dress code, appearance is neat and clean.
• Completes annual educational requirements.
• Maintains regulatory requirements, including all state, federal and CMS regulations.
• Maintains Hospital HIPAA requirements, policies and standards on patient confidentiality at all times.
• Consistently completes and maintains assigned duties.
• Attends Hospital and Department in-services as scheduled.
• Attends HIM Department staff meetings as scheduled.
• Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.
• Actively participates in the departments CQI activities.
• Communicates the mission, vision, core values of the Hospital.
• Ensures compliance with policies and procedures regarding department operations.
• Complies with all organizational policies regarding ethical business practices.
• Other duties as assigned

Regulatory Requirements:

• High school graduate or equivalent.
• Certified in medical Coding (CPC)
• Previous hospital experience as a Coder strongly preferred.
• Knowledge of diagnosis/procedure coding in accordance with ICD-10-CM coding guidelines required.

Working Conditions:

Work is conducted in an office setting requiring extended periods of time in a seated or standing position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising patient care. Employee may be exposed to infectious and contagious diseases, exposed to hazardous cleaning agents, body fluids and waste, minimal exposure to an unpleasant patient or unit elements. Employee may be required to exert up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently. These are baseline requirements for adequate performance of this job. Employees may be required to exceed these levels. Job duties are based on an average 8-hour shift but are subject to change dependent upon staffing volumes or other variables determined by department director or Administration.