Overview
Position: Coder Inpatient Level III. The role involves interacting extensively with physicians and other members of the health care team to improve the quality, completeness, and accuracy of medical record documentation. This supports the clinical picture and severity level for appropriate reimbursement and informs core measure abstraction and coding processes.
Responsibilities
Coordinate and provide education to physicians and other clinicians on compliant documentation, coding, and abstraction issues.
Identify opportunities for documentation improvement to ensure accuracy and completeness used for measuring and reporting physician and hospital outcomes (e.g., patient safety indicators and hospital acquired conditions).
Collaborate with other disciplines to communicate opportunities for referral to the appropriate performance improvement committee for resolution.
Review inpatient medical records using nationally recognized guidelines to assure accurate and complete documentation of diagnoses and procedures and DRG assignment.
Demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, MS-DRG, APR-DRG, secondary diagnosis, and risk-adjustment methodologies, and the impact of procedures on the final DRG.
Qualifications
Education : High School diploma required. Associate of Science in Health Information Technology preferred. RHIA preferred. AHIMA-approved college coding program or certificate preferred.
Licensure/Certification : Certified Coding Specialist (CCS) required.
Knowledge of Core Measures, HAC, and AHRQ PSI/Harm Measures preferred.
Experience : Minimum 5 years inpatient acute care coding (recent hands-on production) experience required. Proficiency in Clinical and Business Applications preferred at time of hire; training will occur if needed within 30-60 days from date of hire.
Performance expectations are outlined on the Assessment and Evaluation Tool.
Work Environment & Total Rewards
This active position requires the ability to work in a busy patient care area. Near visual acuity and comfortable use of multiple computer applications are required. The Health Data Integrity Specialist works independently with minimal supervision. Strong critical thinking and customer service skills are required.
The essential functions for this position are listed on the Assessment and Evaluation Tool.
Total Rewards at AtlantiCare : AtlantiCare offers a market-competitive Total Rewards package designed to promote physical, emotional, social, and financial well-being, including:
Generous Paid Time Off (PTO)
Medical, Prescription Drug, Dental & Vision Insurance
Retirement Plans with employer contributions
Short-Term & Long-Term Disability Coverage
Life & Accidental Death & Dismemberment Insurance
Tuition Reimbursement
Flexible Spending Accounts (FSAs) for healthcare and dependent care
Wellness Programs
Voluntary Benefits (e.g., Pet Insurance)
Note: Benefits offerings may vary based on position and eligibility requirements.
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