Must be able to pass Coder II test at 80%.

Contract - duration 6 months -1 year
Full Time - 40 hrs/week
 
Experience in Inpatient, Outpatient, and ED preferred

Education/License/Certification
* This position requires certification as a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information  Administrator (RHIA).
* Completion of classes in medical terminology, anatomy and physiology, ICD-9 and CPT coding conventions, and disease process from an accredited program.
* Must have high school diploma or GED.

Qualifications
* Must have at least three (3) years hospital inpatient experience coding within the last five (5) years.
​​Minimum experience with ICD 10 - 6 months
All candidates must have a minimum of 6 months of ICD 10 experience.
Candidates must have experience with CPT codes AND must be comfortable with CPT codes.
Ideal candidate has strong CPT experience.
Must be able to code IP, OPS, OBV, OP excellent experience in Inpatient/Outpatient w/experience in ED
Demonstrated ability to understand the clinical content of a health record, including the most complicated records
Must also be able to communicate with physicians in order to clarify diagnoses/procedures and sequencing of diagnoses.
Ability to demonstrate knowledge of and utilize auditing skills related to coding quality and compliance
Must be able to meet quantity and quality standards established for Coders II.
Basic PC skills.
Will abide by the AHIMA coding code of ethics.

Preferred Qualifications
Background knowledge analysis, assembly, terminal digit filing, and physician’s incomplete processing preferred.

Duties
* Review medical records to identify diagnoses/procedures. Independently organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements.
* Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-9-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.
* Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data Including the most complicated encounters/cases.
* Assigns Codes.
* Codes all diagnostic and operative information from the medical record using ICD-9-CM, CPT and HCPCS coding classification systems and independently quality checks own work.
* Selects the DRG for each inpatient case.
* Optimizes hospital payment legitimately and ethically by utilizing approved coding guidelines and conventions.
* Reviews DRG discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment.
* Verifies and abstracts, all medical data from the record to complete a data abstract on each hospital encounter. Corrects data as appropriate.
* Ensures that all data abstracted is consistent with guidelines outlined by JCAHO, OSHPD and CMS, regional and local policy.
 
Completion of Medical Records
* Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
* Enters patient information into the computerized inpatient and outpatient medical record databases, ensuring the accuracy and integrity of the medical record abstract data prior to transmitting case to Government Reimbursement for billing.
* Ensures timely record availability by meeting established coding and abstracting productivity standards.
* Independently conducts medical record documentation auditing to monitor physician compliance with regulatory requirements i.e., Physician Review Project.
 
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.
 
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.
 
Other Duties
* Answers the telephone promptly and identifies themselves and the department.
*Acts as an expert resource person to other coders and personnel in other hospital departments regarding coding questions and issues.
* Other duties as assigned by supervisors.