HEALTH INFORMATION MANAGEMENT CODER - HEALTH INFORMATION MANAGEMENT

Health Information Management Coder

Under the supervision of a Coding Supervisor, the Health Information Management (HIM) Coder abstracts relevant clinical and demographic information from the medical record to identify the care rendered to the patient for the purpose of reimbursement, research and compliance. The HIM Coder ensures that the medical record reflects accurate attending physician documentation for coding of physician and facility encounters. Assigns ICD-10-CM and PCS codes, CPT-4, and HCPCS Level II codes in accordance with coding and reimbursement guidelines for physician and facility encounters. Abstracts into a group and assigns Diagnosis Related Group (DRG) on inpatient accounts and applies Ambulatory Payment Classifications (APC) to outpatient accounts. With minimal errors, identifies principal and secondary diagnosis and procedures based upon federally mandated requirements, corporate requirements, and hospital policy. Maintains productivity standards and quality accuracy of 95% or above.

Typical duties include identifying and coding the principal and secondary diagnosis and procedures using ICD-10-CM and PCS, E/M, CPT-4, and HCPCS Level II codes with minimal errors as needed. Sequences diagnoses and procedures in accordance. Abstracts specific data and enters into the clinical abstracting database. Utilizes the encoder and other related databases and references to minimize coding errors. Attends departmental required in-service and training in-service programs. Adheres to section/departmental procedures for work assignments. Meets quality and productivity standards. Adheres to the Departmental Standard Practices Guidelines. Adheres to Hospital attendance policies. Adheres to environmental requirements. Meets the standard for compliance of Continuing Education (CE) as defined by the American Health Information Management Association (AHIMA) or other licensing/certification agency. Performs assignments as scheduled with or without supervision. Maintains the confidentiality of information. Maintains a cooperative working relationship with the Health Information Management team. Works flexible hours including weekends, holidays and various shifts. Performs other duties as assigned, as required.

Minimum qualifications include a High School Diploma or G.E.D., one (1) year of coding experience within the last two (2) years, and one of the following certifications: Registered Health Information Administrator (RHIA) (AHIMA), Registered Health Information Technician (RHIT) (AHIMA), Certified Coding Specialist (CCS) (AHIMA), Certified Coding Specialist-Physician Based (CCS-P) (AHIMA), or Certified Professional Coder (CPC) (AAPC).

Preferred qualifications include Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).

Knowledge of Microsoft Office Excel and Word, working knowledge of ICD9-CM and PCS, ICD10-CM and PCS, CPT-4, and HCPCS Level II Codes, excellent verbal and written communication skills, ability to code utilizing a computerized encoder/abstracting system, ability to operate a PC in a windows environment, ability to multi-task and meet deadlines in a fast paced and stressful environment, ability to adhere to department policies and standards utilizing best practices, ability to maintain a professional demeanor and composure when challenged, ability to work flexible hours, including weekends, ability to maintain a high level of discretion and maintain confidentiality, demonstrate attention to detail, accuracy and precision.

This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements.

Benefits package includes medical, dental, and vision coverage, basic term life insurance, pension plan, deferred compensation program, paid holidays, vacation, and sick time. You may also qualify for the Public Service Loan Forgiveness Program (PSLF).