Inpatient Facility Medical Coder Remote - Vodastra

Inpatient Facility Medical Coder - Remote

Location: Clackamas, OR, US
Healthcare
Salary: USD $27.26 – $32.00 / hr
 

Job Description:

Candidates must reside either in Washington or Oregon to be considered for this position.

To independently and efficiently perform the responsibilities of assigning accurate diagnosis and procedure codes to patients' health information records for Emergency Department (ED), Ambulatory Surgical Center (ASC), Hospital Ambulatory Surgical Center (HAS), Observations (OBS), Inpatient (IP), and other selected facility records. Maintain an acceptable level of performance in quality and productivity for ICD-10-CM, ICD-10-PCS, and HCPCS/CPT classification and nomenclature systems. All work will be carried out in accordance with: International Classification of Diseases - Official Coding Guidelines as established by the Centers for Medicare and Medicaid Services (CMS) and the National Center for Health Statistics (NCHS); American Medical Association (CPT); National Correct Coding Initiative (NCCI); Uniform Hospital Discharge Data Set (UHDDS), Medicaid (OMAP), and the organization's/institutional coding directives. Ability to communicate with physicians to obtain clarification for diagnoses/procedures. Ability to understand the clinical content of the health record and abstract the data in the patient health information record data as well as perform other duties assigned. The position requires the new coder to be on-site for one (1) week of training or until they meet the department's expectations.

Essential Responsibilities:

• Proficient in medical record review and translating clinical information into coded data.
• Identify and assign appropriate codes for diagnoses, procedures, and other services rendered, while also validating any Computer Assisted Coded (CAC) assignments for dual coding.
• Utilize the Code Base Charge Trigger system (CBCT) and OPTUM 360 EncoderPRO software system for professional surgical services, analyzing and maintaining systems accuracy, validity, and meaningfulness for both professional and facility services.
• Utilize electronic patient data system and clinical information system (EpicCare) to access patient encounter information. Abstract and enter clinical data elements as defined by the needs of the organization.
• Identify and assign principal diagnosis and procedure codes, sequencing them as needed for proper Ambulatory Payment Classification (APC), Medicare Severity-Drug Related Group (MS-DRG), All Patients Refined Diagnosis Related Groups (APR-DRG) assignment, utilizing applicable coding conventions.
• Demonstrate knowledge and understanding of CMS HCC Risk Adjustment coding.
• Routinely perform chart analysis to identify areas of the medical record that contain incomplete, inaccurate, or inconsistent documentation.
• Review and verify chart information (i.e., POS, attending provider). Assess and input data.
• Review and verify component parts of medical records to ensure completeness and accuracy of diagnostic and therapeutic procedures that must conform to CMS coding rules and guidelines.
• Meet and maintain department standards 95% for productivity and quality.
• Coding Auditor Senior spends a minimum of 80% of work time assigning codes to Inpatient records.
• Fully utilize resources available such as Coding Clinic and CPT Assistant to research issues to apply coding guidelines.
• Identify coding concerns and inform supervisors, managers as appropriate. Utilize query process when appropriate.
• Assist in implementing solutions to reduce back-end coding errors.
• Stay current on coding and regulatory publications, attend workshops to stay abreast of current issues, trends, changes in laws and regulations governing medical record coding and documentation to mitigate the risk of fraud and abuse and to optimize revenue recovery.
• May assist with special projects. Maintain confidentiality and effective working relationships with staff.
• Communicate in a clear and understandable manner, exercise independent judgment.
• Review annual ICD-10 Official Guidelines for Coding, along with review of quarterly Coding Clinic and monthly CPT Assistant.
• Perform as a team member of Facility Coding Services, and actively participate with peers in coding in-services, staff meetings, reporting of performance measures, and quality outcome monitors.
• May participate in the development of organizational procedures. Attend and participate in selected national and regional coding education sessions.
• Perform other duties as assigned.

Qualifications:

Basic Qualifications:

• Experience: Minimum five (5) years of experience in coding with four (4) years of inpatient facility coding or minimum four (4) years in the Coding Auditor position with proficiency in inpatient coding.
• Education: High School Diploma or General Education Development (GED) required.
• License, Certification, Registration: The candidate must have 1 from the following list:
  • Registered Health Information Technician Certificate
  • Coding Specialist Certificate
  • Registered Health Information Administrator Certificate

Additional Requirements:

• Previous experience with EMR patient documentation system with intermediate knowledge and skill in the use of a computer.
• Advanced knowledge of disease processes, diagnostic and surgical procedures, Inpatient ICD-10-CM, ICD-10-PCS, HCPCS/CPT classification systems, health information/medical record department responsibilities with knowledge of government regulations and areas of scrutiny for potential fraud and abuse issues.
• Advanced knowledge of medical terminology, pharmacology, and medical coding principles for ICD-10-CM, ICD-10-PCS, HCPCS/CPT and coding.
• Fluent in English, demonstrating skill and proficiency in oral and written communication.
• Skills in time management, organization, and analytical skills.
• Ability to manage a significant workload and to work efficiently under pressure meeting established deadlines with minimal supervision.
• Ability to use independent thought and judgment.
• Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).
• Meet and maintain department standards for performance, productivity, and quality.
• Department will furnish the final candidate with a coding skill test. The candidate will be required to pass with a 75% or better on the test.
• Academic knowledge and working experience performing coding and abstracting responsibilities in health information/medical record services.

Preferred Qualifications:

• Minimum five (5) years of experience in a health information/medical record environment, with facility coding experience that includes Medicare reimbursement guidelines.
• Degree in Health Information Management.
• Proficient knowledge and skill in the use of a computer and related systems and software, including EMR(s), Microsoft Office Suite, and other software programs.
• Ability to evaluate, analyze, and develop information regarding mathematical statistics and percentages that compare finding trends and outcomes related to productivity and/or medical record audits.
• Extensive knowledge of ICD-10 coding guidelines, with knowledge and demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements.

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