A Brief Overview

Responsible for accurately and timely coding of moderate to complex community or tertiary inpatient encounters independently following established coding, CMS regulations and hospital guidelines. Accurately codes diagnostic and procedural information following official coding guidelines, facility specific guidelines and federal regulations.

What You Will Do

• Reviews moderate to complex medical records to identify sequence, code diagnoses and procedures according to established coding, CMS and hospital guidelines in order to accurately code inpatient encounters.
• Coding Technical Skills- ICD-10-CM, ICD-10-PCS, MS-DRG's, APR-DRG's, ROM, SOI, and POA Assignment. Understanding of CC/MCC's, HCC's, HAC's, PSI's, and impacts on quality reporting.
• Collaborates with and supports the Clinical Documentation Integrity Team. Follows Facility query policy and DRG Reconciliation process.
• Maintains or exceeds productivity and quality rate according to established standards.
• Works within UH Billing time frames.
• Maintains coding knowledge and skills via written coding resources, clinical information and educational webinars. Maintains knowledge of guidelines and regulations affecting the UHHS Coding Department. Maintains up to date credentials.
• Utilizes critical thinking/problem solving processes.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).
• Abstracts selected data items and enters in 3M encoder/Epic software with accuracy and attention to detail.
• Consistently follow coding guidelines and uses coding references to accurately select the appropriate principle diagnosis, secondary diagnosis(s) and procedure(s).
• Demonstrates proficiency in reviewing moderate to complex cases.
• Demonstrates effective time management skills by completing assignments within time constraints and calendar schedule.

Additional Responsibilities

• Participates in educational and informational activities as required.
• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.

Education

• Associate's Degree preferably in HIM (Required)  
• Bachelor's Degree (Preferred)

Work Experience

• 2+ years ICD-10 CM and ICD-10-PCS coding experience (Required)

Knowledge, Skills, & Abilities

• Medical terminology, anatomy/physiology, pathophysiology and pharmacology knowledge (Required proficiency)
• Individual must be detail-oriented and organized, with good analytic and problem solving ability. (Required proficiency)
• Self-motivated with ability to function independently and as a team player in a fast-paced environment. (Required proficiency)
• Must have strong written and verbal communication skills. (Required proficiency)
• Demonstrated ability to use PCs, Microsoft Office suite, and general office equipment (i.e. printers, copy machine, FAX machine, etc.). Must be able to proficiently work within with multiple systems. (Required proficiency)

Licenses and Certifications

• Certified Professional Coder (CPC) (Required) or
• Certified Coding Specialist (CCS) (Required) or
• Registered Health Information Technologist (RHIT) (Required) or
• Registered Health Information Administration (RHIA) (Required) or
• Certified Inpatient Coder (CIC) (Required)

Physical Demands

• Standing Occasionally
• Walking Occasionally
• Sitting Constantly
• Lifting Rarely up to 20 lbs
• Carrying Rarely up to 20 lbs
• Pushing Rarely up to 20 lbs
• Pulling Rarely up to 20 lbs
• Climbing Rarely up to 20 lbs
• Balancing Rarely
• Stooping Rarely
• Kneeling Rarely
• Crouching Rarely
• Crawling Rarely
• Reaching Rarely
• Handling Occasionally
• Grasping Occasionally
• Feeling Rarely
• Talking Constantly
• Hearing Constantly
• Repetitive Motions Frequently
• Eye/Hand/Foot Coordination Frequently

Travel Requirements

• 10%25