Careers >> HIM Outpatient Ambulatory Coder - Remote
HIM Outpatient Ambulatory Coder - Remote
Summary
Title:HIM Outpatient Ambulatory Coder - Remote
ID:109038
Department:Health Information Management
Location:Oakland, CA
Description
***PLEASE NOTE THAT ALL CANDIDATES MUST BE AHIMA CERTIFIED***
 Please write hours and days of availability on the upper right corner of the resume.
 
CANDIDATES WILL BE REQUIRED TO TAKE AND PASS THE HIM OUTPATIENT/AMBULATORY CODER TEST WITH A 80% OR BETTER.
Successfully passing the coding test is required regardless of experience.

Minimum Qualifications:
Education -
Must have a high school diploma or GED
Certification - CCA/CCS - 
Experience - Must have have 3 years of continuous hospital experience in coding/abstracting within the last 5 years.
Demonstrated knowledge of anatomy and physiology, medical terminology, disease processes, basic knowledge of reimbursement methodologies (DRGs, APCs) and conventions, rules, guidelines for current coding classifications (ICD-10-CM, CPT, HCPCS Level II).
Demonstrated ability to understand the clinical contents of a health record.
Demonstrated ability to communicate with physicians in order to clarify diagnoses/procedures and properly sequence them for coding.
Must be able to meet quantity and quality standards.
Must maintain minimum CE hours. Must maintain a minimum of ten (10) CE hours annually.
Must maintain current coding credential. Will abide by the AHIMA coding code of ethics. 

Description:
HIM Outpatient Ambulatory Coder 
Working from the appropriate documentation in the medical record, assigns codes and modifiers with ICD-10-CM, CPT, and HCPCS Level II codes where needed.
When assigned, review and if necessary correct codes that have been assigned by an Outpatient/Ambulatory coder to ensure that they have been completed in accordance with the rules, regulations, and coding conventions of ICD-10 CM official guidelines for coding and reporting, Coding Clinic published by the American Hospital Association, the ICD-10-CMcode book, CPT, CPT Assistant, CMS, NCCI edits, OSHPD and Client’s organizational/institutional coding guidelines. 

Essential Duties and Responsibilities:
1)Review medical records to identify diagnoses/procedures: 
Under general supervision, organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements.
Demonstrates an in depth, expert level of knowledge of all guidelines concerning the coding and sequencing of diagnoses and procedures as outlined in but not limited to ICD-10-CM, CPT, Uniform Hospital Discharge Data Set (UHDDS), Medicare guidelines and other sources.
Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding Emergency Department (ED), Hospital Observation (HOPS), Hospital Ambulatory (HAS), Hospital Outpatient (HOV).
Acts as a resource person to other hospital departments regarding coding questions and issues.

2)Assigns Codes:
Under supervision, codes all diagnostic and operative information from the medical record using ICD-10-CM, CPT and HCPCS coding classification systems.
Verifies and abstracts all medical data from the record to complete a data abstract on encounters in the following settings: Emergency Department (ED), Hospital Observation (HOPS), Hospital Ambulatory (HAS), Hospital Outpatient (HOV).
Corrects data as appropriate.
Ensures that all data abstracted and coded are consistent with ICD-10-CM Official Guidelines for Coding and Reporting, as well as those guidelines outlined by CPT, CPT Assistant, CMS, UHDDS, JCAHO, NCQA, OSHPD, and Client's regional and local policies. 

3)Medical Record Peer Review:
Participates in quality improvement for coding, abstracting, and/or APC assignments. 

4)Completion of Medical Records:
Under general supervision, interacts with physicians to clarify and promote accurate documentation of patient diagnostic and procedural information.
Enters patient information into the computerized outpatient medical record databases, ensuring the accuracy and integrity of the medical record abstract or encounter data prior to transmitting case.
Ensure timely record completion by meeting coding and abstracting productivity/quality standards.
Participates in medical record documentation auditing to monitor physician compliance with regulatory requirements i.e., Physician Review Project in concert with appropriate managers. May provide physician review and education based on review findings. 

5)Quality Standards:
Measured bi-weekly and reported in 4-week increments:
Average weekly between 85 - 90 simple HOV charts/day
Average weekly between 85 – 90 ED charts/day
Average weekly between 35 – 45 Ambulatory Surgery & complex HOV charts/day
Average weekly between 10 - 12 Edit Correction charts/hour

Based on audits of 20 or more charts per year:
95% DRG/APCs
95% principal diagnosis
98% discharge disposition. 

6)Productivity Standards:
During the first six (6) months of tracking these productivity numbers, these numbers will be used to provide educational opportunities for the Coders. 

7)Confidentiality/Security of Systems:
Maintains and complies with policies and procedures for confidentiality of all patient records.
Demonstrates knowledge of security of systems by not sharing computer logons. 

8)Corporate Compliance Accountability:
Consistently supports the precepts of Corporate compliance and Principles of Responsibility by maintaining confidentiality, protecting the assets of the organization, acting with integrity, reporting observed fraud and abuse and complying with applicable state, federal and local laws and program policies and procedures.
Consistently demonstrates the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors. 

9)Competencies to perform the job successfully: 
An individual should demonstrate the following competencies: 
Problem Solving – Identifies and resolves problems in a timely manner; gathers and analyzes information skillfully; develops alternative solutions. 
Customer Service – In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Cleints Service Quality Credo, the Clients Mission as well as specific departmental/organizational initiatives.
Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our members, and to purchasers, contracted providers and vendors. 
-Interpersonal Skills – Maintains confidentiality; treats co-workers, patients and facility visitors with respect. 
-Oral Communication – Listens and gets clarification to ensure that instructions and requests are fully understood. 

10)Physical Demands:
The physical demands described here are representative of those that must be met by an incumbent to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Ability to sit for long periods of time at a computer terminal.
Ability to lift, push or pull 11 to 20 pounds.
Occasional bending, stooping, kneeling, crouching, reaching.
Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements.
Ability to concentrate and maintain accuracy in spite of frequent interruptions.

11)Work Environment:
The work environment characteristics described here are representative of those an incumbent encounters while performing the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

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