Job Description

Location: Steward Health Care
Posted Date: 1/9/2023

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

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.

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

WORKING CONDITIONS: (Place X's where applicable)

Physical Requirements

Activity

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 conditions

Activity

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:

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: ________________

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.

Application Instructions

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