The Facility Inpatient Coder is responsible for accurately assigning all reportable diagnoses and procedures for complete and accurate coding of a medical record, per Official Coding and Reporting Guidelines. The Inpatient Clinical Coder’s primary responsibilities are related to accurately and completely coding all inpatient accounts assigned by the company's clients.
• Promotes a partnership between clinical documentation and financial outcomes, by accurately and completely coding the medical record for all appropriate ICD-10 CM and ICD-10 PCS codes. • Ensures all diagnoses and Present on Admission indicators are captured per Official Coding and Reporting Guidelines to ensure accurate DRG assignment (MSDRG and/or APRDRG) on accounts coded, while also capturing any additional, secondary diagnoses that impact quality outcomes (ex: Risk of Mortality, Severity of Illness, Social Determinants of Health, HCC, etc.) to ensure accurate and complete coding. • Ensures all procedures are captured per Official Coding and Reporting Guidelines to ensure accurate DRG assignment (MSDRG and/or APRDRG) on accounts coded, while also capturing any additional procedure codes for add-on payment options that do not necessarily change the DRG (ex: New Technology Add On Payment codes/NTAP) but impact facility reimbursement. • Validates the discharge disposition accuracy as part of the coding review. • Stays current with Official Coding Guidelines, Quarterly Coding Clinic, and NTAP criteria to ensure high quality of codes assigned by the company. • Abides by the “Standards of Ethical Coding” as set forth by the American Health Information Management Association. • Demonstrates actions consistent with company's “Expectations” as duties are performed daily.
• Complete mandatory annual HIPAA and Compliance Training in a timely manner • Maintain confidentiality in all matters to include patient care, physician, and employee matters • Maintain accurate and reliable organizational records • Maintain professional relationships with appropriate officials; communicate honestly and completely; behave in a fair and nondiscriminatory manner in all professional contacts • Assure the accuracy of data, work, or information and contribute ideas and suggestions to improve approaches, methodologies, and productivity. • Maintain professional relationship with clients focusing on high level of client satisfaction • Adhere to a personal plan of professional development and growth through professional affiliations, activities, and continuing education driven by professional goals and quality audit outcomes • Demonstrates excellent observation skills, analytical thinking, problem solving, plus good verbal and written communication. • Professional, team player, able to communicate well with others. Strong interpersonal skills, pleasing personality, positive. • Support overall strategic goals of the company
• Must have a dedicated secure workspace to ensure adherence to HIPAA Privacy and Security policies and procedures when viewing protected health information (PHI) • High-speed internet connection • Telephone • Company will provide laptop and access to necessary resources to perform job duties
• Associate degree* • Health Information Technology with AHIMA Registered Health Information Technician (RHIT) credential preferred. • AHIMA certification (CCS, RHIT or RHIA) required. • Minimum of 5 years of facility inpatient coding experience required. • Recent experience coding level I trauma/academic inpatient charts required.• Ability to work independently in a remote setting required. *Relevant work experience in absence of associate degree will be considered on a case-by-case basis.
• Flexible. Ideally M-F during regular business hours, 40 hrs/week. 100% remote. CA residents NOT accepted. • Overall physical workload is light. Ability to communicate both orally and in writing. Work is generally sedentary requiring long periods at workstation. • Travel may be required occasionally
Productivity: Will be coding complex chart types, ranging from $400k-$1million charts.
Systems: EPIC and 3M experience required.