| Title: | HIM Hospital Coder II |
|---|---|
| ID: | 24839 |
| Department: | Health Information Management |
| Location: | Bellflower, CA |
1 full time at 40hrs/week,
Testing Administered
Ability to code anything - Inpatient, Outpatient and ED. Flexible hours for coverage.
THIS POSITION WILL REQUIRE A HEALTH SCREEN
Education/License/Certification
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
Must have high school diploma or GED.
Qualifications
Must have at least three (3) years continuous hospital inpatient experience coding within the last five years.
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.
Duties:
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 knowledge of all procedures concerning the sequencing of diagnoses, procedures as outlined in but not limited to 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 outpatient encounter or inpatient discharge data. The above duty statements are intended to describe the general nature and level of work being performed by individuals assigned to positions in this classification and, as such, are not intended to be construed as an exhaustive list of duties, responsibilities and skills required of every position so classified.
Assigns Codes: Under direct supervision: Codes all diagnostic and operative information from the medical record using ICD-9-CM , CPT, HCPCS level 2 coding classification systems. Selects the DRG for each inpatient case. 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 hospital encounters. Corrects data as appropriate. Ensures that all data abstracted and/or coded are consistent with guidelines outlined by JCAHO, OSHPD and CMS, regional and local policy.
Completion of Medical Records: Under general supervision, 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 or encounter data prior to transmitting case. Ensures timely record availability by meeting coding and abstracting productivity / quality standards established for Coders I. Participates in medical record documentation auditing to monitor physician compliance with regulatory requirements i.e., Physician Review Project.