Job Description

Location: Steward Health Care
Posted Date: 3/23/2022

Responsible for assigning diagnostic and procedural codes to patient charts of moderate to high complexity using ICD-10- CM and ICD-10-PCS or any other designated coding classification system in accordance with coding rules and regulations. Abides by the Standards of Ethical Coding as set forth by AHIMA. Abstracting required clinical information from the medical record.

KEY RESPONSIBILITIES:

  • Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures.
  • Adheres to Standards of Ethical Coding (AHIMA).
  • Reviews medical records to determine accurate required abstracting elements including appropriate discharge disposition.
  • Demonstrates ability to achieve 95% or higher accuracy and consistency in the selection of principal and secondary diagnoses and procedures.
  • Knowledge of MS-DRG and APR DRG classification and reimbursement structures
  • Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM and ICD-10-PCS coding.
  • Attends mandatory coding seminars on annual basis for inpatient coding. Quarterly review of AHA Coding Clinic.
  • Communicates and resolves coding issues (lacking documentation, physician queries, missing documentation, second level review, DRG reconciliation, etc.) for appropriate follow-up and resolution
  • Candidate must display a superior knowledge of Coding Guidelines (Coding Clinic, UHDDS Official Coding Guidelines,CCI Edits).
  • Comprehensive understanding of CCs/MCCs, impact on quality reporting, UHDDS guidelines, HACs and PSIs
  • Analytical Skills that include effective evaluation, synthesis and use of information gathered
  • Works collaboratively with CDI, Quality, and other facility(ies) leadership
  • Experience with compliant physician querying writing
  • Candidate must be self-motivated, display a high level of computer literacy, excellent verbal, and written communication skills, able to meet assigned deadlines, and organized

REQUIRED KNOWLEDGE & SKILLS:

  • One to three years’ experience performing medical record coding in acute care setting required
  • Associate of bachelor’s degree in Health Information, Nursing, or other related field, or formal coding classes completed and passed preferred. Years of coding experience will be considered in lieu of education requirements.
  • Meditech experience preferred. Functional Knowledge of EMR (Electronic Medical Record), Encoder and CDI Tools and other Support Software
  • Microsoft Office (Word, One Note, Excel, Outlook, PowerPoint)

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

  1. Education: RHIT or RHIA preferred
  2. Experience: 1 - 3 year of Acute Inpatient Coding Experience
  3. Certification/Licensure: AHIMA or AAPC approved credential
  4. Software/Hardware: 3M experience required
  5. Other: Remote position

Application Instructions

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