CORE VALUES Compassion Accountability Respect Excellence |
Steward Health Care System
Job Description
TITLE: Inpatient Coder | JOB CODE / GRADE: ADS-1698 |
DEPARTMENT: HIM/Coding/CDI Operations | FLSA STATUS: Non Exempt |
REPORTS TO: Inpatient Coding Manager | DATE: 10/1/2021 |
POSITION SUMMARY: (Briefly describe the overall purpose of this position - Why does it exist and how does it contribute to the overall organization?) |
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: (Use bullets for specific 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. Attends Quarterly Coding Updates and all coding conference calls
- 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
- The position will report to the HIM Inpatient Coding Manager
- Ability to meet coding productivity standards
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REQUIRED KNOWLEDGE & SKILLS: (Examples: Ability to work independently and take initiative; Good judgment and problem-solving skills; Communication skills; Interpersonal and organizational skills; Level of confidentiality) |
- One to three years’ experience performing medical record coding in acute care setting required
- High school graduate or equivalent is 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)
- Excellent verbal and written communication skills
- Ability to meet assigned deadlines.
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EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER: |
- Education: RHIT or RHIA preferred
- Experience: 1 - 3 year of Acute Inpatient Coding Experience
- Certification/Licensure: AHIMA or AAPC approved credential
- Software/Hardware: 3M experience required
- Other: Remote position
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WORKING CONDITIONS: (Place X's where applicable) |
Physical RequirementsActivity | Amount of Time Spent | | None | Up to 25% | 25%-50% | 50%-75% | 75%or More | Stand/Walk | | | | | | Use Hands to Finger, Feel, Reach w/Hands & Arms, Climb, or Balance | | | | | | Stoop, Kneel, Crouch, or Crawl | | | | | | Talk or Hear | | | | | | Taste or Smell | | | | | | Other | | | | | |
Lifting Requirements Amount of Pounds | Amount of Time | | None | Up to 25% | 25%-50% | 50%-75% | 75% or More | None | | | | | | Up to 10 lbs. | | | | | | Up to 25 lbs. | | | | | | Up to 50 lbs. | | | | | | Up to 100 lbs. | | | | | | Over 100 lbs. | | | | | |
Vision Requirements Vision Requirements | Needed | Not Needed | Close Vision | | | Distance Vision | | | Color Vision | | | Peripheral Vision | | | Depth Perception | | | Ability to Adjust Focus | | | Other | | |
WORK ENVIRONMENT Exposure to the following environmental conditionsActivity | Amount of Time Spent | | None | Up to 25% | 25%-50% | 50%-75% | 75%or More | Outdoor Weather Conditions | | | | | | Extreme Cold (Non-Weather) | | | | | | Work in High Precarious Place | | | | | | Risk of Electrical Shock | | | | | | Risk of Radiation | | | | | | Blood-Borne Pathogens | | | | | | Flammable, Explosive Gases | | | | | | Toxic or caustic Chemicals | | | | | | Dust or Other Irritants | | | | | | Grease or Oils | | | | | | Infections From Disease Bearing Specimens | | | | | | Infectious/Contagious Diseases | | | | | | Cleaning Agents/Chemicals | | | | | | Hot or Noisy Equipment | | | | | | Humid or Wet Conditions (Non-Weather) | | | | | | Other | | | | | | | | | | | | | Very Quiet | Quiet | Moderate | Loud | Very Loud | Level of Noise that is Typical in the Work Environment | | | | | |
Safety Equipment Used When Performing This Job: | Yes | No | | Yes | No | | Yes | No | Safety Eyeglasses | | | Surgical Mask: | | | Gloves: | | | Filter Lens (Welding/Soldering): | | | Gowns: | | | Other: (List Below) | | | Face Shields: | | | Boots: | | | | | | Ear Plugs or Mufflers: | | | Hard Hat: | | | | | | Dust Mask: | | | Coveralls: | | | | | |
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SIGNATURES: |
I have been given a copy of this position description and have read and will comply with the expectations and requirements outlined in this position description. Employee Name: _____________________________________________ | | Employee Signature: __________________________________________ | Date: ________________ | Manager Name: ______________________________________________ | | Manager Signature: ___________________________________________ | Date: ________________ | | |
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Disclaimer: The above information on this description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.