JSMCHIMOutpatientCoder

JOBSUMMARY

ResponsibleforthecodingofdiagnosesandproceduresonSDS, OBS and OB Triage outpatientmedicalrecords.Initiatingphysicianqueriesasappropriatetoobtainclarifyingormorespecificdocumentation.Ability to accurately assign ICD-10-CM/PCS and CPT-4 codes to complex outpatient encounters such as observation, outpatient surgery and obstetrics.

FUNCTIONALDEMANDS

Reportsto:

CodingManager and/or HIM Director

InclementWeather:

Non-essential

JOBREQUIREMENTS

MinimumEducation

HighSchoolgraduateorGEDequivalent.CCS or CPC required.AssociatesinHealthInformationManagement(orsimilar program) from an accredited program preferred.

MinimumWorkExperience

Medicalterminologyandanatomyandphysiologyrequired.Minimumoftwo (2)years'experienceinoutpatientcarehospital basedICD-10-CMandCPT-4 codingrequired.WorkingknowledgeofAHACoding Clinics and Local Coverage Determination Policies.

RequiredSkills

Experiencedwithelectronicmedicalrecord.Exceptional communication(verbalandwritten)andinterpersonalcommunicationskills;abilitytointeractwithalllevelsofthe organizationeffectively;possesshighleveloforganization.

RequiredCertifications

CCS or CPCcertificationrequired.RHIT-newgradsconsidered(mustobtaincertificationwithin6monthsof hire.)

ORGANIZATIONALEXPECTATIONS

OrganizationalExpectations

·Providesapositiveandprofessionalrepresentationoftheorganization.

·Promotes culture of safety for patients and employees through proper identification, reporting, documentation, and prevention.

·Maintains hospitalstandards foraclean andquietpatient environmenttomaintain apositivepatient careexperience.

·Maintainscompetencyandknowledgeofcurrentstandardsofpractice,trends,anddevelopmentsinrelatedscopeofjobrole orpractice.

·Adheres to infection-control policies and protocols, medication administration and storage procedures, and controlled substanceregulations.

·Participatesinongoingqualityimprovementactivities.

·Maintainscompliancewithorganization’spolicies,aswellasestablishedpractices,protocols,andproceduresoftheposition, department, and applicable professional standards.

·Complieswithorganizationalandregulatorypoliciesforhandlingconfidentialpatientinformation.

·Demonstrates excellent customer service through his/her attitude and actions, consistent with the standards contained in the Vision, Mission, and Values of the organization.

·Adherestoprofessionalstandards,hospitalpoliciesandprocedures,federal,state,andlocalrequirements,andTJCstandards and/or standards from other accrediting bodies.

·AsaStuderPartnermusthavetheabilitytodevelopafullunderstandingoftheStuderGrouppracticesandtoolsand communicateeffectively.MustembracetheStuderPhilosophyandPrincipalsbyconductinghim/herselfinaprofessional manner.

WillbeheldaccountabletothefollowingStuderPhilosophiesand Principles:

•HCAPSPatientPerception

•HourlyRoundingwithintention

•BedsideShiftReport

•AIDET

•DailyHuddles

NONESSENTIAL FUNCTIONS

DemonstratesabilitytobeflexibleandcompletesallotherdutiesasneededbyCodingDataQualityManagerorDirectorof Health Information Management.

Otherdutiesasassigned.

ESSENTIAL FUNCTIONS

·AccuratelyandcompletelycodesallSDS, OBS and OB Triagerecords,toensureassignedcodesconformtocurrentcodingconventions, achieving 95% accuracy in code assignment.

·Calculates the observation hours when coding Observation accounts. Provides notification to assigned point of contact in PatientFinancialServicesfortheobservationhoursthatarerequiredtobebackedoutoftheobservationhoursthatare billed.

·Performscodingconsistentwithproductivitybenchmarks.

·Consultsprovidersforclarificationsandadditionaldocumentationpriortocodeassignmentwhenthereisconflictingor ambiguous data in the health record.

·DemonstratesanunderstandingofotherpaymentmethodologiesthatuseclinicaldatasuchasAmbulatorySurgeryCenter (ASC) payment groups, Ambulatory Payment Groups (APG) and Resource Based Relative Value Scale (RBRVS)

·PerformsweeklyreviewofUn-Codedaccountsformissedaccountsandcodesthosenotedifnecessarydocumentationis present.

CCS or CPCcertificationrequired.RHIT-newgradsconsidered(mustobtaincertificationwithin6monthsof hire.)

Minimumoftwo (2)years'experienceinoutpatientcarehospital basedICD-10-CMandCPT-4 codingrequired.