Job Description

Location: Morton Hospital
Posted Date: 9/8/2022

At Steward Health Care System, we are committed to improving the health of our communities by delivering exceptional, personalized behavioral health care with dignity, compassion and respect. Our continued focus on the patient experience informs our caregivers in how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values.

We dedicate ourselves in the communities we serve to delivering affordable health care to all and being responsible partners. No matter what your role, as a member of the Steward family, you are a specialist in the making every patient and family feel right at home, every co-worker a key to our success, and every referring practice, a team of prized colleagues.

In support of this, we commit ourselves to the following values:

Compassion

Accountability

Respect

Excellence

Stewardship

If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.

***Medical Records Coder 40hrs/Days

POSITION SUMMARY:

Reviews hospital medical records and/or reports to determine all diagnoses and procedures; assigns the correct ICD10-CM and/or CPT code; adheres to accepted coding conventions; accurately inputs information into Meditech for purposes of reimbursement and clinical and financial decision making

KEY RESPONSIBILITIES:

Reads and interprets health record documentation to identify all diagnoses and procedures that affect the inpatient/outpatient stay/visit

Assesses the adequacy of health record documentation to ensure that it supports all diagnoses and procedures to which codes are assigned

Applies knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to assign accurate codes to diagnoses and procedures

Applies knowledge of current approved coding guidelines (as published in Coding Clinic for ICD10-CM) to assign and sequence the correct diagnosis and procedure codes for hospital inpatient services with a 95% accuracy rate

Applies knowledge of current coding guidelines and regulatory agency guidelines to assign the correct diagnosis and procedure codes for hospital outpatient services with a 95% accuracy rate

Applies knowledge of CPT format, guidelines and notes to locate the correct codes for all services and procedures performed during the encounter/visit and sequence them correctly

Applies Uniform Hospital Discharge Data Set (UHDDS) definitions to select the principal diagnosis, principal procedure, complications and cormorbid conditions, and other diagnoses and significant procedures which require coding

Applies knowledge of the Prospective Payment System to confirm DRG assignment which ensures optimal reimbursement

Refuses to fraudulently maximize reimbursement by assigning codes that do not conform to approved coding principles/guidelines

Applies knowledge of the Outpatient Prospective Payment System to confirm APC/APG assignment which ensures optimal reimbursement

Applies knowledge of ICD10-CM instructional notations and conventions to locate and assign the correct diagnostic and procedural codes and sequence them correctly

Attaches modifiers to procedure or service codes when applicable

Accurately codes for the professional vs. technical component when needed

Clarifies conflicting, ambiguous, or nonspecific information appearing in the record by consulting the appropriate physician

Participates in quality assessment to ensure continuous improvement in ICD10-CM and CPT coding and collection of quality health data

Demonstrates the ability to recognize potential coding quality issues from an array of data

Accurately enters data into Meditech, verifying any existing information

REQUIRED KNOWLEDGE & SKILLS:

  • Is responsible for ongoing development of his/her work skills through the use of available resources (i.e.: inservices, formal educational programs, other work groups and on-the-job training).
  • Attends and participates in staff meetings and inservices and/or reviews documentation as required.
  • Assists in the orientation of others and actively participates in mentoring.
  • Performs analytical and decision making functions with minimal supervision.
  • Recognizes and seeks assistance/consultation when appropriate.
  • Demonstrates an understanding of relative Hospital and all-departmental policies and procedures including safety issues.
  • Possesses awareness of programs/services provided by Hospital and where they are located

EDUCATION/EXPERIENCE/LICENSURE/TECHNICAL/OTHER:

Required Qualifications:

Two to four years coding experience in a health care setting

Working knowledge of ICD10-CM and CPT-4 coding systems

Preferred Qualifications:

Certified Coding Specialist or Accredited Health Information Technician credentials preferred


Additional Information

Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.

Important COVID message

Please note, Morton Hospital is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment - with confidence and without fear. Our Safe and Ready program consists of a rigorous [five-point] standard ensuring patient safety, confidence and convenience: Expanded hours will allow previously cancelled procedures to be scheduled as quickly as possible. Any COVID-19 related care takes place in designated areas away from other patients and their families. Emergency Departments are reorganized to be a safe place to treat all emergency patients. A stringent cleaning policy has been implemented throughout the hospital. A strictly controlled visitor and masking policy is required for patient safety. You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.

This position is subject to the COVID-19 Vaccination Policy for Steward Health Care Workforce. Employees in this position will be required to provide adequate proof of vaccination for COVID-19 by an FDA-approved vaccine prior to starting work. Steward will consider requests for exemptions from this vaccine requirement on the basis of medical condition or sincerely held religious belief in accordance with applicable Federal laws.

Application Instructions

Please click on the link below to apply for this position. A new window will open and direct you to apply at our corporate careers page. We look forward to hearing from you!

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