Note: The job is a remote job and is open to candidates in USA. Veterans in Healthcare is seeking a HIM Coder I to work fully remote. The role involves accurately coding and abstracting medical records using various coding systems while ensuring compliance with federal and state coding regulations.
Responsibilities
- Outpatient Ancillary/Clinic Visit/Emergency Department coding of all diagnostic and procedural information from the medical records using ICD-10-CM, ICD-10-PCS, and CPT/HCPCS, and Modifier classification systems and abstracting patient information as established and required by official coding laws, regulations, rules, guidelines, and conventions
- Reviews the entire medical record; accurately classify and sequence diagnoses and procedures; ensure the capture of all documented conditions that coexist at the time of the encounter/visit, all medical necessity diagnoses, complications, co-morbidities, historical condition or family history that has an impact on current care or influences treatment, and all external causes of morbidity
- Enter patient information into inpatient and outpatient medical record databases (ClinTrac/HDM). Ensures accuracy and integrity of medical record abstracted UB-04 & OSHPD data elements prior to billing interface and claims submission
- Works cooperatively with HIM Coding Support and/or Clinical Documentation Improvement Specialist in obtaining documentation to complete medical records and ensure optimal and accurate assignment of diagnosis & procedure codes
- Assists in the correction of regulatory reports, such as OSHPD data, as requested
- Attendance, punctuality, and professionalism in all HIM Coding and work related activities
- Consistently assumes responsibility and displays reliability for completion of tasks, duties, communications and actions. Completes tasks accurately, legibly, and in a timely fashion
- Performs other duties as requested/assigned by Director, Manager, Supervisor, or designee
- Ability to achieve a minimum of 95% coding accuracy rate as determined by any internal or external review of coding and/or department quality review(s)
- Ability to achieve a minimum of 95% abstracting accuracy rate of UB-04 and OSHPD data elements as determined by any internal or external review of coding and/or department quality review(s)
- Assist in ensuring that all medical records contain information necessary for optimal and accurate coding and abstracting
- Recognizes education needs of based on monthly reviews and conducts self-improvement activities
- Ability to act as a resource to coding and hospital staff on coding issues and questions
- Ability to improve MS-DRG assignments specific to the documentation & coding of PDx, SecDx, CC/MCC, PPx, and SecPx in accordance with official coding laws, regulations, rules, guidelines, and conventions
- Ability to improve APR-DRG, SOI, and ROM assignments specific to the documentation & coding of PDx, SecDx, CC/MCC, PPx, and SecPx in accordance with official coding laws, regulations, rules, guidelines, and conventions
- Ability to improve APC/HCC assignments specific to medical necessity documentation & coding of PDx, SecDx, and CPT/HCPCS in accordance with official coding laws, regulations, rules, guidelines, and conventions
- Maintains at minimum, expected productivity standards (See HIM Practice Guidelines) and strives to maintain a steady level of productivity and provides consistent effort
- Works coding queues/task lists to ensure 95% of patient bills are dropped within 5 days after patient discharge/date of service
- Works coding queues/task lists to ensures the remaining 5% of patient bills are dropped within 2 weeks of discharge/date of service
- Assist other coders in performance of duties including answering questions and providing guidance, as necessary
- Assists Patient Financial Services (PFS), Patient Access, and other departments in addressing coding issues/questions and/or providing information so that an interim bill can be generated. Assists with physicians, physician office staff and hospital ancillary department staff with diagnostic or procedural coding issues/questions, as needed
- Assists in the monitoring unbilled accounts to ensure that the oldest records are coded and/or given priority
- Maintains AHIMA and or AAPC coding credential(s) specified in the job description
- Attend coding & CDI seminars, webinars, and in-services to maintain the required annual continued education units (CEU)
- Keep up-to-date and reviews ICD-10 Official Guidelines for Coding & Reporting, AHA Coding Clinic, and CPT Assistant to maintain knowledge of the principles of coding
- Keep up-to-date and reviews other professional journals and newsletters in a timely fashion to maintain knowledge of the principles of coding
- Consistently attend and actively participate in the daily huddles
- Consistently adhere to HIM policies and procedures as directed by HIM management
- Demonstrates an understanding of policies and procedures and priorities, seeking clarification as needed
- Participates in continuously assessing and improving departmental performance
- Ability to communicate changes to improve processes to the director, as needed
- Assists in department and section quality improvement activities and processes (i.e. Performance Improvement)
- Works and communicates in a positive manner with management and supervisory staff, medical staff, co-workers and other healthcare personnel
- Ability to communicate effectively intra-departmentally and inter-departmentally
- Ability to communicate effectively with external customers
- Provides timely follow-up with both written and verbal requests for information, including voice mail and email
- Working knowledge and efficient navigation of the Electronic Health Record (EHR): Cerner/Powerchart & Coding mPage
- Working knowledge, efficient navigation, & full use of 3M-CRS Encoder system; utilize to expedite coding process; utilize all references
- Knowledge & understanding of PFS system (PBAR) functionality and any interface with the coding abstracting system: ClinTrac
- Working knowledge, efficient navigation, & full use of ‘HDM/HRM/ARMS Core’ coding & abstracting software
- Working knowledge, efficient navigation, & full use of ‘3M 360 Encompass/CAC’
- Performs other duties as assigned
Skills
- High School or equivalent
- Specialized/technical training Successful completion of college courses in Medical Terminology, Anatomy & Physiology, and a certified coding course
- Successful completion of the hospital specific OP coding test – with a passing score of ≥70
- Experience in using a computerized coding & abstracting database software and an encoding/codefinder systems are required
- Demonstrates excellent verbal and written communication skills
- Organization/time management skills
- Able to function independently and as a member of a team
- Demonstrate excellent customer service behavior
- Certified Coding Specialist - CCS (AHIMA) or AHIMA Certified Coding Associate (CCA); or AHIMA Certified Coding Specialist - Physician (CCS-P); or AAPC Certified Professional Coder (CPC); or AAPC Certified Outpatient Coding (COC) or AAPC Certified Inpatient Coder (CIC)
- Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date
- Prior experience in ICD-9 & ICD-10 (combined) and CPT/HCPCS coding of Outpatient Ancillary/ED medical records in hospital and/or outpatient clinic preferred
- Working knowledge of CPT-4 and ICD-9CM coding and computerized billing systems such as IDX
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