The Health Information Management Coder Inpatient Level 2 provides timely and accurate clinical and administration data to ensure optimal reimbursement for inpatient, rehab and/or skilled nursing coding to support the facility needs. Primary patient contact is only social.

Demonstrates excellent customer service performance in that his/her attitude and actions are at all times consistent with the standards contained in the Vision, Mission and Values of Covenant HealthCare and the commitment to providing Extraordinary Care for Every Generation.

• Contributes to organization success targets for patient satisfaction.
• Formulates and uses effective working relationships with all members of the HIM department, physicians, external customers, patients, and other department staff members.
• Adheres to current coding rules, regulations and requirements for inpatient coding, DRG/APR-DRG assignment, rehab coding, skilled care coding, CMG assignment, IRFPAI completion, inpatient coding CCI edits, POA assignment and other to ensure quality coding based upon documentation within the patient record.
• Codes all inpatient charts varying from neonatal to geriatric, medical, surgical, critical care, and trauma.
• Performs a thorough review of all clinical information to identify the principal diagnosis, secondary diagnoses, procedures, comorbid conditions and complications and the impact of clinical documentation that lead to a final DRG/APR-DRG assignment. When documentation is conflicting or unclear, a retrospective query will be sent to providers to assure correct assignment of codes and final DRG. Coders may also identify missed concurrent query opportunities and follow up accordingly by providing detailed feedback and justification including clinical picture, coding guidelines, coding references, etc.
• Follows policies, procedures, and guidelines to assure consistent coding quality. At the same time, utilizes analytical skills when reviewing charts, interpreting documentation, and applying codes, DRG’s, sufficing edits, etc.
• Supports concurrent Clinical Documentation Program by completing chart reviews and entering information in CDI software, works closely with and often directs the CDS staff to ensure optimal DRG, APR DRG, and documentation. Compares the CDI working DRG on CDI charts to the final Coder DRG. Shares knowledge with CDI’s regarding the accuracy of the clinical documentation that lead to the final DRG assignment.
• May also be required to work with external vendors/customers on issues, audits, or projects.
• Helps to identify solutions to problems and assists in resolving issues.
• Assures coding is completed timely and all work queues are maintained at a reasonable completion rate/turnaround timeframe. This includes the willingness to help others, accepting help from others and the ability to work extra when backlogs occur.
• Participates in HIM department meetings and area specific meetings (IPC, IPC/CDS, clinical areas, resident/physician meetings, etc.) as required.
• Assist in achieving departmental, AR and area specific goals.
• Participates in identifying lean opportunities to enhance coding efficiency and lower AR.
• Shares knowledge during training of new staff and is a resource to others.
• Independent learning with desire for continues personal and professional growth. Stays current on coding updates such as Coding Clinics, code updates/changes.
• Utilizes numerous references to support technical decisions, clinical understanding of disease processes or procedures/tests performed.
• Maintains professional credentials.
• Assist CBO/Finance/Data/CMG/ Patient Safety and Quality/Other as requested for follow up on items related to coding, billing, reimbursement, and State reporting/other. Assure that all legal requirements, including federal (HIPAA) and Ate regulations are followed.
• Demonstrates an awareness of legal/confidentiality issues and adheres to all HIPAA Privacy and Security and department policies and procedures.
• Participates in the development and attainment of department and workgroup goals.
• Performs other duties as assigned which may include reviewing, analyzing coding denials, denial appeals, denial entry, writing appeal letters to outside agencies, coding quality reviews, training of new staff, mentoring students, or testing for new software upgrades.
• Help develop or maintain guidelines, procedures, or policies.

EDUCATION/EXPERIENCE REQUIREMENTS

RHIA, RHIT, or CCS credential required.

Eligible Bachelor or Associate Degree graduates will be considered with the expectation they pass the national exam.

Acute care inpatient coding experience preferred (inpatient diagnosis, inpatient procedures coding utilizing ICD10CM/ICD10PCS coding books and references).

Clinical documentation knowledge for inpatient coding strongly preferred.

KNOWLEDGE/SKILLS/ABILITIES

• Basic computer skills.
• Must be able to tolerate working under stress, limited constraints and with frequent interruptions and deadlines.
• Knowledge of standard office equipment.
• Knowledge of computer use including EMR, email/Outlook, internet, 3M encoder and other software as needed (Lawson, Word, Excel).
• Demonstrates effective communication methods and skills, both verbally and in writing.
• Uses appropriate organization/priority setting skills to complete work timely and accurately.
• Practices effective problem identification and resolutions skills as a method of sound decision making.
• Demonstrates interpersonal skills required to work with many other people and personalities.
• Ability to use sound judgement, based upon the latest guidelines, federal and state statutes, and regulations, as well as hospital and departmental policies.
• Ongoing professional growth in many areas.
• Ability to sit and look at computer screen for long periods of time.
• Ability to be flexible to adjust assignments as priorities change.

WORKING CONDITIONS/PHYSICAL REQUIREMENTS

• Ability to maintain regular, punctual attendance consistent with the ADA, FMLA and other federal, state and local standards.
• Constant sitting, use of hands to finger, handle and feel.
• Constant hearing and near vision.
• Frequent depth perception, midrange and far vision.
• Frequent color and field of vision.
• Frequent lifting 0-10lbs.
• Occasional standing, walking, carrying, pushing, pulling, climbing, balancing, stooping, kneeling, crouching, squatting and crawling.
• Occasional twisting, reaching and talking.
• Occasional lifting 11-50lbs. ICIMCHNonNJ