Documentation Specialist Coder
This position is responsible for accurately assigning diagnostic and procedure codes to records of inpatient, observation, ambulatory surgery, emergency department, and other outpatient encounters and abstracting patient information as required. The Documentation Specialist acts as subject matter expert and resource on coding-related activities.
Responsibilities:
- Maintain and establish department policies and procedures, objectives, quality assurance program, safety, environment and infection control standards.
- Possess in-depth knowledge of the conventions, rules, and guidelines of multiple classification systems, including ICD-10 diagnosis and procedures and CPT.
- Possess in-depth knowledge of disease process in multiple medical/surgical specialties.
- Review patients entire current medical records and utilize encoder software and/or code books to assign appropriate diagnosis codes using the International Classification of Diseases, 10th Edition Clinical Modification (ICD-10-CM) following coding guidelines and the predetermined department standards.
- Determine the sequence of diagnoses according to uniform hospital discharge data.
- Review surgical and designated diagnostic procedure documentation to assign appropriate procedure codes using the International Classification of Diseases, 10th Edition, Procedure Coding System (ICD-10-PCS) and/or Current Procedural Terminology (CPT) using encoder software and/or code books.
- Determine and record other required data items including, but not limited to attending physician, discharge disposition, number of consultations, referral source and similar data.
- Query physicians or other providers to obtain documentation clarification/specificity or other information required for accurate code assignment.
- Assist in care and maintenance of department equipment and supplies; maintain department records, reports and files as required.
- Participate in educational programs and in-service meetings; attend other meetings as required.
- Advise the medical staff, business office, QRM and other staff on coding issues.
- Ensure final bill pending report is within target and that charts are coded within specified timeframes.
- Retrieve records for closing out each month and make corrections to coded and abstracted information as required.
How You'll Be Successful:
Work Experience: At least 3 years of previous coding experience, or an associate or bachelor's degree in a CAHIIIM accredited program Required
Education: High school diploma or equivalent Required
Licenses and Certifications: Certified Coding Associate (CCA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician (CCS-P), Certified Inpatient Coder (CIC), Certified Outpatient Coder (COC), Certified Professional Coder (CPC), Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) Upon Hire Required
A Place Where You Belong:
We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children's Health a place where everyone can contribute.
Holistic Benefits How We'll Care for You:
- Employee portion of medical plan premiums are covered after 3 years.
- 4%-10% employee savings plan match based on tenure
- Paid Parental Leave (up to 12 weeks)
- Caregiver Leave
- Adoption and surrogacy reimbursement
As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally-protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.