Clinic Medical Record Coder

Job Description

Utilizes technical coding expertise to assign appropriate ICD-10-CM and ICD-10-PCS codes to complex inpatient visit types. Complexity is measured by a Case Mix Index (CMI) and Coder II's typically see average CMI's of 2.2609. This index score demonstrates higher patient complexity and acuity.

Utilizes expertise in clinical disease process and documentation, to assign Present on Admission (POA) values to all secondary diagnoses for quality metrics and reporting.

Thoroughly reviews the provider notes within the health record and the Findings from the Clinical Documentation Nurse in the Clinical Documentation Improvement (CDI) Department who concurrently reviewed the record and provide their clinical insight on the diagnoses.

Utilizes resources within 3M 360 CAC (Computerized Assisted Coding) software to efficiently review documentation and select or assign ICD-10-CM/PCS codes using autosuggestion or annotation features.

Reviews Discharge Planning and nursing documentation to validate and correct, when necessary, the Discharge Disposition which impacts reimbursement under Medicare's Post Acute Transfer Policy.

Utilizes knowledge of MS-DRG's, APR-DRG's, AHRQ Elixhauser risk adjustment to sequence the appropriate ICD-10-CM codes within the top 24 fields to ensure correct reimbursement.

Collaborate with CDI on approximately 45% of discharges regarding the final MS or APR DRG and comorbidity diagnoses.

Educates CDI on regulatory guidelines, Coding Clinics and conventions to report appropriate ICD-10-CM diagnoses.

Interprets health record documentation using knowledge of anatomy, physiology, clinical disease process, pharmacology, medical terminology to determine the Principal Diagnosis, secondary diagnoses and procedures.

Follows the ICD-10-CM Official Guidelines for Coding and Reporting, ICD-10-PCS Official Guidelines for Coding and Reporting, Coding Clinic for ICD-10-CM and ICD-10-PCS, coding conventions and instructional notes to assign the appropriate diagnoses and procedures.

Utilizes coding expertise and knowledge to write appeal letters in response to payor DRG downgrade notices.

Resolves Nosology Messages/Alerts and Coding Validation Warning/Errors.

Meets established coding productivity and quality standards.

EPIC or Cerner Experience preferred. 3M 360 CAC experience required

Position Requirements

A minimum of three years' experience is required in an Academic Medical Center with Inpatient Coding experience.

Current CCS, CIC, RHIA, or RHIT certification.

Position requires excellent computer/communication skills for provider and staff interactions.

Candidate must have ability to handle multiple projects and appropriately prioritize tasks to meet deadlines.

Candidate must have excellent organizational skills, able to understand and follow individual client Standard Operating Procedures.

#J-18808-Ljbffr 6AM City, LLC