HIM Coder III, FT, Variable

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Job Summary

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. To perform Inpatient coding by assigning International Classification of Diseases-Clinical Modification (ICD-CM) and International Classification of Diseases-Procedure Coding System (ICD-PCS) codes as well as the Diagnosis Related Groups (DRG) assignment. Major Complications and Comorbidities/Complications and Comorbidities (MCC/CCs), Hospital-Acquired Condition/Patient Safety Indicator (HAC/PSI) and Quality Indicators capture as appropriate through documentation validation. To code for multiple facilities. Adhere to Prisma Health Coding and Compliance policies and procedures for assignment of complete, accurate, timely and consistent codes.

Accountabilities

• Applies ICD-CM and ICD-PCS codes to complex inpatient records, including major traumas, cardiac/open health and Neonatal Intensive Care Unit (NICU) records based on review of clinical documentation.  Assigns the DRG, MCC/CCs, HACs and PSI that most appropriately reflect documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department policies and procedures. 
  80%
• Review work ques daily to identify charts that need to be coded and prioritizes as per department-specific guidelines and within designated time lines. 3%
• Identify and request physician queries following established guidelines when existing documentation is unclear or ambiguous following American Health Information Management (AHIMA) guidelines and established policy.  2%
• Adheres to department standards for productivity and accuracy. 10%
• Follows up on priority  accounts daily for final coding. 1%
• Identifies and trends coding issues escalating identified concerns to coding leadership. 1%
• Interacts with team members to review for other coders. 1%
• Demonstrates proficiency in utilizing official coding books as well as the electronic medical record, computer assisted coding/encoding software, and clinical documentation information systems to facilitate coding assignment. 1%
•  Performs other duties as assigned. 1%

Minimum Education

Certification Program; Associate's Degree or Coding Certificate through American Health Information Management (AHIMA) or other approved coding certification program.

Minimum Experience

4 years

Required Certifications/Registrations/Licenses

Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Coding Specialist  or other approved coding credential.

Work Shift

Variable (United States of America)

Location

Patewood Outpt Ctr/Med Offices

Facility

1001 Corporate Services - Upstate

Department

10017512 HIM-Coding

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