Job Title
Individual responsible for coding all hospital ED, RCR, CLI, REF records for purposes of reimbursement, research, and compliance with federal regulations.
Responsibilities
- Reviews patient's entire current medical record and assigns appropriate ICD-10 diagnosis and CPT procedure codes according to accepted coding guidelines and hospital's policies and procedures.
- Assigns accurate APC and E-APG's to patient's record utilizing hospital encoding system.
- Corrects any edits flagged by encoder and financial system.
- Understands and applies modifiers appropriately.
- Charge entry.
- Accurately abstracts statistical data from records using hospital abstracting system.
- Attends hospital sponsored coding educational programs and department coding meetings.
- Participates in and practices lean management principles and processes.
DCH Standards:
- Maintains performance, patient and employee satisfaction and financial standards as outlined in the performance evaluation.
- Performs compliance requirements as outlined in the Employee Handbook
- Must adhere to the DCH Behavioral Standards including creating positive relationships with patients/families, coworkers, colleagues and with self.
- Performs essential job functions in a manner that ensures the safety of patients, visitors and employees.
- Identifies and reduces unsafe practices that may result in harm to patients, visitors and employees.
- Recognizes and takes appropriate action to reduce risks and hazards to promote safety for patients, visitors and employees.
- Requires use of electronic mail, time and attendance software, learning management software and intranet.
- Must adhere to all DCH Health System policies and procedures.
- All other duties as assigned.
Qualifications
- Associates or bachelor's degree in Health Information Technology from an AHIMA/CAHIIM accredited college or graduate of an AHIMA accredited medical coding program.
- 1 year of hospital coding experience.
- Must pass the DCH coding proficiency assessment for outpatient coders.
- Some computer or computerized encoder experience required.
- RHIA, RHIT, CCS or CIRCC preferred.
Working Conditions
Work Context
- Requires the ability to work 8 hours quietly at a computer screen and keyboard/mouse.
- Must be able to meet deadlines as assigned.
- Requires the ability to withstand pressures of constant deadlines, audits, educational demands and changing healthcare environment.
- Must have ability to accept criticism and to deal calmly and effectively in high stress situations.
- Must be able to communicate both verbally and in writing on a daily basis.
- Must be able to participate in groups.
- Must be able to adapt to changes in work area as assigned.
- Displays a willingness to take on responsibilities and challenges.
- Ability to maintain confidentiality.
Physical Factors
- Hearing and vision must be normal or corrected to within normal range.
- Able to perform the duties with or without reasonable accommodation.
- This job is considered light work. Must be able to exert up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.
- This job involves standing, walking, sitting, stooping, pushing, pulling, and crouching.
- Ability to lift up to 20 pounds occasionally and 10 pounds frequently.
- Must have good dexterity.
- Should be able to reach and extend arms in any direction.