Coder I - Medical Records - Full Time/Days - Req#2117962768

Brief Description Job Objective: Under the supervision of the Coding Manager of Health Information Services, the coder is responsible for timely review of patient records to identify an appropriate selection of codes that accurately reflect the reason for admission, extent of care received, and level of severity of illness. The coder ensures that all data elements required for federal or state reporting and billing are collected and included in the patient's demographic record. Duties and Responsibilities Coding and Abstracting Reviews and screens the entire medical record to abstract designated statistical data and enters the information in the abstract database accurately and timely. Codes, sequences, and groups to appropriate APC after identifying the principal diagnosis and procedure as documented in the records, ensuring optimum reimbursement for outpatient and emergency department records for all payer types. Uses various software applications to analyze and ensure appropriateness of codes and sequencing, and addresses any applicable edits. Contacts the physician and/or ancillary department when additional information is needed to accurately code and records holding reasons in the abstracting database. Keeps abreast of regulatory changes affecting coded information required by CMS, the Office of Statewide Health Planning Department, Uniform Billing requirements, Official Coding Guidelines, and others. Reviews encounters holding for billing on a regular basis and follows up as necessary to ensure timely release of bill. Selects appropriate assignments for coding/abstracting from the work queue based on daily priorities. Data Quality Coding Generates, evaluates, and distributes various coding and abstracting data related to quality metrics. Follows up and addresses discrepancies in the coding and abstracting data. Ensures OSHPD corrections are worked appropriately and in a timely manner. Follows re-bill guidelines. Routes identified registration errors as defined by process and records holding reasons in the abstracting database. Other Duties Assists hospital staff, medical staff, public, and other stakeholders as needed. Plans, organizes, prioritizes, and coordinates work to achieve functional area goals and maximum productivity and efficiency on a day-to-day basis. Answers telephones consistently with Service Excellence standards, addressing and/or routing calls appropriately and timely. Protects the confidentiality of primary and secondary health records and releases information as mandated by law, professional standards, and the hospital's policies. Non-Essential Duties Accepts and carries out other miscellaneous duties and responsibilities as required for maintaining the services provided by Medical Records. Knowledge, Skills and Abilities Knowledge Microsoft Office Department policies, practices, and procedures Medical diagnostic and procedural terminology Understanding of disease processes, anatomy, and physiology necessary for assigning accurate codes Knowledge of encoders and related software Knowledge of federal and state regulations and requirements pertaining to patient care Medical Records functions normally acquired through a minimum of 24 months of Acute Care Medical Records Department experience Skills Interprets handwritten and transcribed documents in the medical record ICD-10-CM and PCS and CPT/HCPCS coding skills Correlates generalized observations and symptoms to a stated diagnosis to assign the correct code Accurately enters data using a keyboard and computer systems for coding and abstracting Effective oral and written communication Attention to detail Abilities Ability to learn advanced aspects of Coding and Reimbursement Ability to review and enter data into various computer systems Ability to review records and verify patient information accurately Core Competencies Accountability, Action Oriented, Customer Focused, Compassion, Effective Communication, Teamwork, Ethics & Values, Integrity & Trust, Education and Experience. Education and Experience High school graduate or GED equivalent. Completion of 1 semester of college level Medical Terminology. Completion of a college level Anatomy and Physiology course. One year of recent coding experience in an acute care facility or ambulatory care facility. Experience with ICD-10-CM, PCS, and CPT/HCPCS classification required. Required Licensure and/or Certifications Certified Coding Specialist or Certified Professional Coder-Hospital preferred. AVH Conduct/Compliance Expectations Adherence to AVH Leaves of Absence Policy Adherence to AVH Paid Time Off (PTO) Policy Adherence to AVH Recording of Hours Worked Policy Adherence to the department dress code Organizes work and establishes priorities Expands on own initiative in performance of duties Follows telephone etiquette/standards Conforms to AVH Standards of Excellence Functions effectively under pressure and meets time parameters Communicates effectively while maintaining good working relationships with coworkers, managers, and other hospital staff Maintains confidentiality of patient, hospital, and department information Adheres to safety rules and regulations Uses equipment safely and effectively to carry out duties Interprets and functions under hospital and department policies and procedures Conforms with required Joint Commission requirements Supports hospital quality assurance and improvement guidelines Participates effectively in department and hospital staff education Displays willingness to work as a team player Provides highest level of patient/customer satisfaction at all times Supports values and mission statement of the AVH Board of Directors Physical Requirements and Working Conditions Work usually performed in a normal office environment, requiring long periods in a sedentary position. Frequent use of keyboard and video display terminal. NOTE: The above statements describe the general nature and level of work performed by people assigned to this job. This document is not an exhaustive list of all responsibilities, skills, and working conditions for the classified personnel. #J-18808-Ljbffr Antelope Valley Medical Center