Health Information Management Coder II/Certified Health Information Management Coder-Inpatient

$5,543.20 – $9,325.33 Monthly

Position Description

Certified Health Information Management Coder-Inpatient classification pay scale: $39.388 – $53.795

Health Information Management Coder II classification pay scale: $31.981 – $43.650

Application materials will be reviewed on an ongoing basis until the position is filled. Please allow up to (2) two weeks for processing of application materials (Postmarks and faxes not accepted). The eligible list established from this recruitment may be used to fill future temporary and permanent positions as vacancies arise. Exam #25/50T06/10SS.

POSITION DESCRIPTION

Natividad is currently seeking to fill one (1) permanent full time Health Information Management Coder II/Certified Health Information Management Coder-Inpatient position in the Health Information Management Department. Under general supervision, reviews, interprets, codes and abstracts medical records information according to standard classification systems; identifies diagnostic categories based on medical, diagnostic and related hospital services rendered and other related patient information; reviews medical records for adherence to quality standards; and performs other related duties as assigned.

DISTINGUISHING CHARACTERISTICS

Health Information Management Coder II: This is the full, journey level class in this series. Incumbents perform the full scope of duties involving the coding of both outpatient and inpatient medical records, and may perform other special assignments as related to the Health Information Management division.

Certified Health Information Management Coder-Inpatient: This is the certified classification in this series. Incumbents possess and maintain certification from the American Health Information Management Association and perform the full scope of duties involving the coding of both outpatient and inpatient medical records. They may perform other special assignments as related to the Health Information Management division.

Examples of Duties

POSITION DESCRIPTION

• Depending upon assignment, reviews and codes inpatient and/or outpatient medical record information; assigns codes using the International Classification of Diseases Manual ICD 10-CM the American Medical Association’s Current Procedural Terminology (CPT) manual, and/or the Healthcare Common Procedure Coding System (HCPCS) codes and modifier assignments; establishes Ambulatory Payment Classification (APC) and/or Diagnosis Related Group (DRG) group appropriateness; identifies and codes secondary diagnoses and/or procedures; ensures compliance with all APC and/or DRG mandates and reporting requirements
• Abstracts Department of Health Care Access and Information (HCAI) data elements and assists the HIM Coding Supervisor with correcting and submitting data
• Monitors Medicare and other DRG paid bulletins and manuals, and reviews the current Office of the Inspector General (OIG) work plans for DRG risk areas
• Evaluates the quality of clinical documentation on a continuous basis to identify incomplete or inconsistent documents for inpatient and/or outpatient encounters that impact the code selection and resulting APC/DRG groups and payment; brings concerns to the attention of the HIM Coding Supervisor and/or medical staff for resolution
• Maintains knowledge of current and required coding certifications as appropriate
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association; reports areas of concern to the HIM Coding Supervisor
• Assists the HIM Coding Supervisor by serving as a facility representative for DRGs and/or APCs by attending coding and reimbursement workshops and bringing back information as appropriate; communicates any DRG/APC updates published in third-party payer newsletters, bulletins and/or provider manuals; shares information with facility staff as directed
• Assists the HIM Coding Supervisor in performing data quality reviews on inpatient records to validate the International Classification of Diseases Manual (ICD-10-CM), and other codes; verifies Diagnosis Related Group (DRG) group appropriateness; checks for missed secondary diagnoses and procedures and ensures compliance with all DRG mandates and reporting requirements; monitors Medicare and other DRG paid bulletins and manuals, and reviews the current Office of the Inspector General (OIG) work plans for DRG risk areas
• Assists the HIM Coding Supervisor in performing data quality reviews on outpatient encounters to validate the ICD-10-CM, the Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS) Level II code and modifier assignments; verifies Ambulatory Payment Classification (APC) group appropriateness; checks for missed secondary diagnoses and/or procedures; ensures compliance with all APC mandates and outpatient reporting requirements; monitors medical visit code selection against facility specific criteria for appropriateness; assists in the development of such criteria as needed
• Monitors unbilled account reports for outstanding services or un-coded discharges to reduce accounts receivable days for inpatients and/or outpatients
• Stays informed of transaction code sets, Health Insurance Portability and Accountability Act (HIPAA) requirements and other future issues impacting the coding function; keeps abreast of new technology in coding and abstracting software and other forms of automation
• Demonstrates competency in the use of computer applications, particularly the coding and abstracting software and hardware currently in use by the Health Information Management division
• Assists the HIM Coding Supervisor in performing periodic claim form reviews to check code transfer accuracy from the abstracting software and the charge master; may serve on a charge master maintenance committee
• Complies statistics and prepares/maintains a variety of records and reports; finalizes attending physician attestations and obtains signatures; researches and locates missing data and records needed for coding and abstracting; retrieves files and records

Examples of Experience/Education/Training

MINIMUM QUALIFICATIONS

For Certified Health Information Management Coder-Inpatient classification only:

Required Certification: Possess and maintain a national certification or registration in health information management coding from the American Health Information Management Association (AHIMA), as a Certified Coding Specialist (CCS), a Registered Health Information Technician (RHIT) or a Registered Health Information Administrator (RHIA).

THE IDEAL CANDIDATE

Will have proven track record demonstrating the following knowledge, skills and abilities:

Thorough Knowledge of:

• Medical record keeping principles and practices; the nature and uses of medical records charges; basic medical terminology, anatomy, and physiology
• Basic function of a hospital medical records division; legal aspects of medical record administration
• ICD-10-CM, CPT, and HCPCS Level II coding systems
• The APC structure and regulatory requirements
• Basic keyboard operations and the operation of standard office equipment; standard business computer hardware and software
• The business and professional relationships and ethics involved among hospitals, physicians and patients
• The current Diagnostic and Statistical Manual of Mental Disorders (e.g., DSM IV-TR)
• Current hospital reimbursement systems and associated regulatory review practices
• Governmental and Joint Commission (TJC) standards for medical records
• States, sequence, progression and description of disease

Skill and Ability to:

• Read, interpret and evaluate complex technical reports and information
• Understand and apply anatomical, physiological and medical terminology
• Operate a personal computer
• Maintain records and compile statistics
• Communicate clearly and concisely, both orally and in writing; prepare reports and other written communications
• Provide excellent public relations and courteous customer service; establish and maintain cooperative working relationships with others including physicians, nurses, administrators, managers, vendors, contractors and other healthcare industry personnel
• Interpret both outpatient and inpatient medical records to assign diagnostic codes and prepare medical record abstracts
• Understand disease processes, advanced medical terminology, diagnostic descriptions and procedures
• Evaluate the quality, completeness and accuracy of medical records
• Work with physicians and others to ensure complete and accurate information and optimal reimbursement based on coding and abstracting of medical records

EXAMPLES OF EXPERIENCE/EDUCATION/TRAINING

Any combination of training, education and/or experience which provides the knowledge, skills and abilities and required conditions of employment listed above is qualifying. An example of a way these requirements might be acquired is:

Experience for Both Classifications: Two (2) years of experience equivalent to the class of Health Information Management Coder I in Monterey County.

and

Education for Both Classifications: Completion of a community college, vocational school, or equivalent program in Medical Records Coding and Abstracting.

Additional Information

CONDITIONS OF EMPLOYMENT

• Natividad requires that all incumbents pass a pre-employment physical/medical assessment.
• Natividad will conduct a thorough background and reference check process which includes a Department of Justice fingerprint check.
• Employees who drive on County business to carry out job related duties must possess a valid CA Driver License for the class vehicle driven and clean driving record.
• Employees must have and show their original Social Security Card and a valid CA Driver License or CA State ID prior to the first day of work.
• Incumbents may be required to work all shifts, including nights, weekends, and holidays;
• Incumbents may be required to work with potentially hazardous and infectious substances.
• REQUIRED APPLICATION MATERIALS AND SCREENING PROCESS**

APPLICATION SUBMISSION: A completed Monterey County Application may be obtained from and submitted to the Natividad Human Resources Office, 1441 Constitution Blvd., Bldg. 300, Salinas, CA. 93906, or On-line applications may be submitted at www.natividad.com; resume and license and/or certifications (if applicable) may be attached to your online application or emailed separately to: SellanAM@natividad.com. Resumes will be accepted in addition to, but not in lieu of the required application materials. For more information or to obtain regular paper application materials please contact the Natividad HR, 1441 Constitution Blvd.,(831) 783-2700, M – F, 7:30 a.m.- 5:00p.m.

QUALIFICATIONS APPRAISAL: All licenses/certificates will be verified via primary source. Completed application materials will be competitively evaluated. Please note: The initial screening for this position uses ONLY the applicant’s answers to the Supplemental Questions. Screeners (who are Subject Matter Experts) are not given the application and/or resumes at this point in the process. Therefore, your answers to the Supplemental Questions are critical. The best-qualified applicants will be invited to participate further in the process.

QUALIFICATIONS ASSESSMENT: To further assess applicants’ possession of required qualifications, this process may include an oral examination, pre-exam exercise, performance exam, or physical ability exam.

ELIGIBLE LIST: Applicants successful in the Qualifications Assessment process will be placed on an eligible list for possible final selection interview. This eligible list will be used to fill current and future vacancies.

SPECIAL NOTES

• If you believe you possess a disability that would require test accommodation, please contact the HR Analyst for Natividad at (831) 783-2749.
• Employment is contingent upon acceptable documentation verifying identity and authorization for employment in the United States.
• If you are hired into this classification in a temporary position, your salary will be hourly and you will not be eligible for benefits.

http://www.co.monterey.ca.us/government/departments-a-h/human-resources/human-resources/benefits/benefit-summary-sheet

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