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Memorial Health Care Center Coder in Owosso, Michigan

JOB SUMMARY:

The Health Information Management (HIM) Coder impacts Memorial’s quality initiatives and reimbursement through the determination of the most accurate and optimal diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing.

Under the supervisor of the Director of Health Information Management, this position is responsible for assigning diagnostic and procedural codes to patient charts of moderate to high complexity using ICD-9-CM, ICD-10-CM, CPT codes, HCPCS codes, creating APC, accurate MS-DRG group assignments accordance with coding rules and regulations. Abides by the Standards of Ethical Coding as set forth by AHIMA. Abstracting required clinical information from the medical record. The HIM Coder will also be responsible for identifying the components of a legal health record, understanding the scanning and patient registration process, basic reimbursement guidelines, data entry, data collection, report writing, computer applications and corporate compliance. Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care.

PRIMARY JOB RESPONSIBILITIES:

  • Maintains productivity levels as established by the Director of Health Information Management with a minimum 98% accuracy rate.

  • Abstracts pertinent information from patient records, assigns ICD-9-CM, ICD-10-CM, HCPCS CPT-4 codes, creating APC or MS-DRG group assignments. Performs review of the health record to ensure all codes are captured and sequenced appropriately.

  • Seeks out missing information and creates complete records, including items such as disease and procedure codes, point of origin code, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons and anesthesiologists, and appropriate signatures/authorizations. Refers inconsistent patient treatment information/documentation to coding quality analysis, supervisor or individual department for clarification/additional information for accurate code assignment.

  • Queries physicians and other healthcare providers when code assignments are notstraight forward or documentation is inadequate, ambiguous, or unclear for coding and legal health record purposes.

  • Keeps abreast of coding guidelines and reimbursement reporting requirements.

  • Maintains appropriate, and demonstrates adequate use of, multiple software applications, including 3-M, various Meditech applications, scanning software, etc.

  • Retrieves, assembles, and analyzes patient records as required by specific patient types.

  • Participates in quality improvement activities, chart reviews, and assists PatientAccounts, Revenue Cycle and Patient Access for clarification byperforming periodic claim reviews for code transfer accuracy as requested.

  • Creates and prints required reports, including not final abstracted to reduce accountsreceivable and assist others in statistical analysis.

  • Assures the patient’s health record is accurate, complete and represents a precise clinical picture of the specific encounter.

  • Completes assigned tasks in appropriate timeframe and adjusts to increasedworkload.

  • Problem solves and brings concerns to Coordinator/Director for resolution when appropriate.

  • Actively contributes to the morale and teamwork of the staff and facility and alwayspresenting a positive attitude and patient-minded vision, with patient satisfaction as the continuing goal.

  • Communicates appropriate information to co-workers and Coordinator. Participatesin in-service and continuing educational activities.

  • Follows established procedures for specific coding modalities, examples – concurrentcoding, outpatient, inpatient, clinics and ancillary coding.

  • Assists with training/orientation of new employees and students.

  • Abides by the Standards of Ethical Coding as set forth by the American HealthInformation Management Association (AHIMA) and adheres to official coding guidelines.

  • Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior.

  • Other duties as assigned.

JOB SPECIFICATIONS:

EDUCATION

  • Associate’s degree in Health Information Technology is required.

  • Minimum of successful completion of a registered coding program with AHIMA approval status, RHIA, RHIT, and CCS is required within one year of hire.

EXPERIENCE

  • One year of Acute Care Hospital coding experience is required.

  • Knowledge of ICD-9-CM, ICD-10-CM, HCPCS, CPT-4, codes, creating APC or MS-DRG group assignments, anatomy, physiology and pathophysiology.

  • Competency in the use of computer applications.

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