Coder I, CodingUS:TX:McAllen | Health Information Management | Full TimeDHR Health - US:TX:McAllen - DaysSummary:Position Summary:Review clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD-10-CM codes for billing, internal and external reporting, research, and regulatory compliance. Accurately code outpatient conditions and procedures as documented in the ICD-10-CM Official Guidelines for Coding and Reporting. Resolve error reports associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors. Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for outpatient encounters. Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures. Utilizes technical coding principals and APC reimbursement expertise to assign appropriate ICD-10-CM diagnoses and procedures. Reviews documentation to verify and, when necessary, correct the patient disposition upon discharge. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.Position Education/Qualifications:CCS-P, CCA, CPC, COC, CIRCC, CTR, CIC, CPC-P, CPC-H, Specialty, or Medical coding certification program preferredJob Knowledge/Experience:Experience and/or training in medical coding, medical terminology and anatomy and physiology required.Requires reasoning ability and good independent judgmentAbility to perform productive research quicklyRequires working with minimal interruptionsMust have an understanding of laws and ethics related to health insurance, medical billing and Health insurance Portability and Accountability Act (HIPAA)Computer and coding software experience required, 3M encoder preferredResponsibilities:Position Responsibilities:Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practicesAccurately Codes outpatient procedures according to most current ICD-10-CM, CPT and APC guidelinesUtilizes computerized 3M Coding SoftwareAbility to code outpatient record types such as: EMR, Radiology, Series, RMF Clinics, etc…Ability to accurately attach HCPCS Level I and Level II modifiers for billing purposesMust meet volume requirements of 120-150 accounts coded dailyMeets quality standards of having 95% of charts coded accuratelyMust take initiative in researching to further his/her own knowledge in codingMust research 3M Coding references for final codingMust be able to validate CPT and procedure descriptionMust be able to identify medical abbreviations, terms and their meaningsMust be able to multitaskMaintains a good working relationship within the department, other departments, and medical staffCodes all available records in a timely mannerMeets productivity standards set forth by the coding managerCommunicates with Coding Manager to solve problems and to clarify coding issuesAssist the business office with clearing reimbursement and denial issuesClears Aeos in a timely mannerCommunicates with other departments to obtain pertinent information related toAttends workshops, seminars or conferences that pertain to position and that fulfill CE hour requirementsReferences updated ICD-10-CM/PCS, CPT, and HCPCS Level II electronic code book references as neededReviews Coding Clinic updates and continuing education periodicals in a timely mannerAdheres to the Health Information Management Policies and Procedures for CodingAdheres to the Coding Compliance PlanFollows the AHIMA Standards of Ethical CodingMaintains confidentiality and safeguards all patient related information.Performs other duties as assignedOther information:Lines Of Responsibilites:(Chain-of-command)1. Coding Supervisor ? 2. Coding Director ? 3. Executive Physician /VP of Medical AffairsCustomer Service:Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.Age Specific:Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status and interpret the appropriate information needed to identify each patient's requirement relative to his or her age.Americans With Disabilities Act (ADA):A. Essential Duties: Indicated by bold print within performance standards, preceding individual numbered criteria.The following table provides physical requirements that will be associated with, but not limited to, this position:Light/moderate lifting up to 20 lbs, from the floor to shoulder height.KneelingMust be able to assist other employees with lifting more than 20 lbs.WalkingLight/moderate carrying up to 20 lbs.Standing/SquattingStraight pullingSittingPulling hand over handPushingRepeated bendingStooping/BendingReaching above shoulderClimbing StairsSimple graspingDual simultaneous graspingDepth Perceptions neededAbility to seeIdentify ColorsOperating office equipmentTwistingOperating mechanical equipmentAbility to read and writeAbility to hear verbal communication without aidOperating Personal VehicleAbility to comprehend written/verbal communicationOther: Ability to deal with stressB. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.D. Aptitudes: HIGH 1 2 3 4 5 6 LOWIntelligence: General learning ability: The ability to "catch on" or understand instructions and underlying principles. Ability to reason and make judgments. 1Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 1Numerical: Ability to perform arithmetic operations quickly and accurately. 3Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to "visualize" objects or two or three dimensions, or to think visually of geometric forms. 3Form Perception: Ability to perceive pertinent details and objects or in pictorial or