Coding Specialist - Inpatient Telecommute

Health Information Coding Specialist

Under the general supervision of the Health Information Coding Manager, reviews the inpatient medical record to assign appropriate codes in accordance with the ICD-10-CM/PCS Official Guidelines for Coding and Reporting. Determines appropriate MS DRGPR DRG assignment for optimal classification and accurate and compliant clinical reporting. Identifies and recommends physician queries when documentation in the chart is incomplete, ambiguous or unclear. Maintains and meets HIS quality and productivity standards.

Brown University Health employees are expected to successfully role model the organization's values of Compassion, Accountability, Respect, and Excellence as these values guide our everyday actions with patients, customers and one another. In addition to our values, all employees are expected to demonstrate the core Success Factors which tell us how we work together and how we get things done. The core Success Factors include: Instill Trust and Value Differences Patient and Community Focus and Collaborate.

Responsibilities include entering into a written Telecommuting Agreement with department management, reading and comprehending the inpatient medical record identifying all treated diagnoses and procedures reporting the correct code(s) adhering to rules set forth in "Official Coding Guidelines," performing coding validation on codes computer-assisted and auto-suggested codes from 3M, understanding clinical documentation to recognize when a query to the physician is required, coding straightforward inpatient medical records such as seen in community hospitals excluding Level 1 trauma cases and complex surgical cases, ensuring the medical record documentation supports the codes selected for the principal diagnosis, secondary diagnoses, complications, co-morbid conditions, procedures and discharge disposition, abiding by the "Standards of Ethical Coding" as set forth by the American Health Information Management Association, entering codedbstracted information and/or validating codes into the 3M DRG grouper assigning utilizing computer-assisted coding tools, assigning accurate MS-DRG or APR-DRG through use of the clinical analyzing functions reviewed in compliance with medical record documentation, adding Present On Admission (POA) indicator to diagnoses, identifying Hospital Acquired Condition and Patient Safety Indicator codes and forwarding to designee, selecting the physician performing procedures ensuring accuracy in the hospital's billing system, working closely with Clinical Documentation Specialist for additional clinical review, responding timely to coding validator coding recommendations, prioritizing high paying records to be completed the day received, performing concurrent coding for in-house patients requiring interim billing, continually meeting coding productivity, quality and accuracy standards, may be required to code rehabilitation records following the established process, consistently meeting established productivity standards and accuracy standards, following-up on all bill holds to ensure timely billing and reimbursement, acting as a resource to physicians and other staff on coding principals and DRG assignments and/or outpatient coding issues, referring coding, billing and system questions to the coding manager or coding validator, seeking supervisory assistance only after exhausting own resources by referencing appropriate coding publications and manuals, assisting other coders with help answering questions and providing guidance to entry-level coders, keeping abreast of coding guidelines and reimbursement reporting requirements, maintaining health information confidentiality by adhering to established organizational and departmental policies and procedures, and performing related clerical and other duties as assigned.

Minimum qualifications include an associate degree required; health information technology preferred (preferably with RHIT or RHIA) and AHIMA CCS Certified Coding Specialist credential. If associate degree is not in health information technology, successful completion of an inpatient coding certification program accredited by AHIMA or the AAPC credential CIC, Certified Inpatient coder. Good writing skills to prepare compliant physician queries. Computer literate; capable of researching internet websites to clarify diseases or procedures. Ability to navigate the patient electronic medical record to access and recognize appropriate data applicable to coding process. Three to five years inpatient coding experience in a teaching or acute care hospital required with proven ability to understand the clinical content of a health record. Trained in medical terminology, anatomy and physiology. Ability to recognize and understand clinical documentation pertinent for coding. Good writing skills to prepare compliant physician queries. Computer literate; capable of research internet websites to clarify diseases or procedures. Ability to navigate the patient electronic medical record to access and recognize appropriate data applicable to coding process.

Working conditions include reading electronic medical records for the entire workday dual computer monitors. Ability to sit for long periods, lift a minimum of 25 pounds, bend, stoop, stretch, use step-stools to file records. Ability to work under stressful conditions to maintain accounts receivable days achieving productivity and accuracy. Performs independently within the department's policies and practices. Refers specific complex problems to the supervisor when clarification of the departmental policies and procedures are required. Supervisory responsibility: None.