|Title:||HIM Hospital Coder II - Onsite|
|Department:||Health Information Management|
|Location:||San Diego, CA|
Home Health/Hospice Experience - ONSITE ONLY
Schedule is Wednesday-Sunday 40 hour/week.
Location : San Diego, CA
Must have experience in Inpatient Coding - Minimum 3 years experience
Must have high school diploma or GED.
Completion of classes in medical terminology, anatomy and physiology, ICD-10 and CPT coding conventions, and disease process from an accredited program.
Certified AHIMA Coder - Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA), etc..
Must have three years of continuous hospital experience in coding.
Demonstrated ability to understand the clinical content of a health record.
Demonstrated ability to communicate with physicians in order to clarify diagnoses/procedures and sequencing of diagnoses.
Basic PC skills.
Must maintain current coding credential as for mentioned.
Will abide by the AHIMA coding code of ethics.
Required Skills for this job:
Coding of Home Health and/or Hospice Charts, check and respond to email
Ability to use Microsoft office – excel, word, Outlook etc.,
Able to receive feedback,
On time and at work daily,
Soft skills-Time management abilities, team player, and positive attitude
As needed, Coders II may assist and be a resource for data integrity for other employees who need clarification and assistance in coding.
Work is performed in accordance with the rules, regulations and coding conventions as established by the American Hospital Association (Coding Clinic), ICD10, CMS, OSHPD and Client's organizational/institutional coding guidelines.
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-10-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-10-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.
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.
Answers the telephone promptly and identifies themselves and the department.
Acts as a resource person to other hospital departments regarding coding questions and issues.
Other duties as assigned by supervisors.