Health Information Management Coder II, FT, Days, – Remote

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Job Summary

To code medical information into the organization billing/abstracting systems and to complete the coding function through established best practice processes and professional and regulatory coding guidelines.

This position will perform moderate to complex Outpatient Surgery, Gastrointestinal (GI) Procedure and Observation coding by assigning International Classification of Diseases (ICD), Current Procedural Terminology (CPT) codes, and documentation validation, coding modifier assignment and attention to HCC codes. Perform Emergency Department, ambulatory clinic, diagnostic and ancillary coding as needed. To code for multiple facilities. Adhere to Prisma Health Coding and Compliance policies and procedures for assignment of complete, accurate, timely and consistent codes. Data reported by this incumbent is used to meet licensure requirements, is used for statistical purposes, and for financial and billing purposes. Incumbent(s) operate under the general supervision HIM Coding leadership.

Accountabilities

• Codes moderate to complex Outpatient Surgery, and Observation records from clinical documentation as well as Emergency department, ancillary and ambulatory clinic records; assigns modifiers as appropriate. Queries physician following established guidelines when existing documentation is unclear or ambiguous following AHIMA guidelines and established policy. -80%
• Queries physician or clinical area following established guidelines when existing documentation is unclear or ambiguous following American Health Information Management Association (AHIMA) guidelines and established policy. – 1%
• Reviews work queues daily to identify charts that need to be coded and prioritizes as per department-specific guidelines and within designated timelines. Follows up on On-hold accounts daily for final coding. – 5%
• Participates in on site, remote and/or external training workshops and training. – 3%
• Responds to and follows up on priority accounts daily and any accounts assigned by Patient Financial services or Coding leader(s) for final coding. Communicates with leader when trending requests volumes impact productivity. – 2%
• Applies ICD and CPT codes to the Emergency department, outpatient ambulatory clinic records and ancillary service records based on review of clinical documentation and according to Official coding guidelines; assigns modifiers as appropriate. – 1%
• Demonstrates continuous learning as evidenced by personally developed reference materials, online publications etc., to stay abreast of new and revised guidelines, practices and terminology, for reference and application. – 1%
• Demonstrates proficiency in utilizing official coding books as well as the electronic medical record and computer assisted coding/encoding software to facilitate code assignment. – 1%
• Adheres to department standards for productivity and accuracy. – 6%

Supervisory/Management Responsibilities

This is a non-management job that will report to a supervisor, manager, director or executive.

Minimum Requirements

• Certification Program. Associate degree or coding certificate through approved American Academy of Professional Coders (AAPC), American Health Information Management Association (AHIMA) or other approved coding certification program.
• 2 years – Coding experience in an acute care or ambulatory setting. Ability to pass internal coding test. Work experience may NOT be substitute for education requirement; prior outpatient coding experience required.

Required Licensures/Registrations/Certifications

Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician (CCS-P), Certified Professional Coder (CPC), Certified Professional Coder-Hospital (CCP-H), or Certified Outpatient Coder (COC) .

Required Knowledge, Skills, Abilities

• Knowledge of electronic medical records and 3M or other Encoder System.
• Ability to concentrate for extended periods of time; ability to solve problems with close attention to detail and to work and make decisions independently.
• Knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process.
• Demonstrated competence in coding and correct extrapolation of official coding and select billing guidelines to specific coding situations.
• Basic computer skills

Work Shift

Day (United States of America)

Location

Corporate

Facility

7001 Corporate

Department

70017512 HIM Coding

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