Job Description

• ## Health Information Management Coder II/Certified Health Information Management Coder-Inpatient##### Overview**Natividad is currently seeking to fill one (1) permanent full time Health Information Management Coder II/Certified Health Information Management Coder-Inpatient position in the Health Information Management Department.** Under general supervision, reviews, interprets, codes and abstracts medical records information according to standard classification systems; identifies diagnostic categories based on medical, diagnostic and related hospital services rendered and other related patient information; reviews medical records for adherence to quality standards; and performs other related duties as assigned.##### Specific Skills**THE IDEAL CANDIDATE***Will have proven track record demonstrating the following knowledge, skills and abilities:****Thorough Knowledge of:**** Medical record keeping principles and practices; the nature and uses of medical records charges; basic medical terminology, anatomy, and physiology* Basic function of a hospital medical records division; legal aspects of medical record administration* ICD-10-CM, CPT, and HCPCS Level II coding systems* The APC structure and regulatory requirements* Basic keyboard operations and the operation of standard office equipment; standard business computer hardware and software* The business and professional relationships and ethics involved among hospitals, physicians and patients* The current Diagnostic and Statistical Manual of Mental Disorders (e.g., DSM IV-TR)* Current hospital reimbursement systems and associated regulatory review practices* Governmental and Joint Commission (TJC) standards for medical records* States, sequence, progression and description of disease***Skill and Ability to:**** Read, interpret and evaluate complex technical reports and information* Understand and apply anatomical, physiological and medical terminology* Operate a personal computer* Maintain records and compile statistics* Communicate clearly and concisely, both orally and in writing; prepare reports and other written communications* Provide excellent public relations and courteous customer service; establish and maintain cooperative working relationships with others including physicians, nurses, administrators, managers, vendors, contractors and other healthcare industry personnel* Interpret both outpatient and inpatient medical records to assign diagnostic codes and prepare medical record abstracts* Understand disease processes, advanced medical terminology, diagnostic descriptions and procedures* Evaluate the quality, completeness and accuracy of medical records* Work with physicians and others to ensure complete and accurate information and optimal reimbursement based on coding and abstracting of medical records##### Responsible For: **POSITION DESCRIPTION** * Depending upon assignment, reviews and codes inpatient and/or outpatient medical record information; assigns codes using the International Classification of Diseases Manual ICD 10-CM the American Medical Association’s Current Procedural Terminology (CPT) manual, and/or the Healthcare Common Procedure Coding System (HCPCS) codes and modifier assignments; establishes Ambulatory Payment Classification (APC) and/or Diagnosis Related Group (DRG) group appropriateness; identifies and codes secondary diagnoses and/or procedures; ensures compliance with all APC and/or DRG mandates and reporting requirements * Abstracts Department of Health Care Access and Information (HCAI) data elements and assists the HIM Coding Supervisor with correcting and submitting data * Monitors Medicare and other DRG paid bulletins and manuals, and reviews the current Office of the Inspector General (OIG) work plans for DRG risk areas * Evaluates the quality of clinical documentation on a continuous basis to identify incomplete or inconsistent documents for inpatient and/or outpatient encounters that impact the code selection and resulting APC/DRG groups and payment; brings concerns to the attention of the HIM Coding Supervisor and/or medical staff for resolution * Maintains knowledge of current and required coding certifications as appropriate * Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association; reports areas of concern to the HIM Coding Supervisor * Assists the HIM Coding Supervisor by serving as a facility representative for DRGs and/or APCs by attending coding and reimbursement workshops and bringing back information as appropriate; communicates any DRG/APC updates published in third-party payer newsletters, bulletins and/or provider manuals; shares information with facility staff as directed * Assists the HIM Coding Supervisor in performing data quality reviews on inpatient records to validate the International Classification of Diseases Manual (ICD-10-CM), and other codes; verifies Diagnosis Related Group (DRG) group appropriateness; checks for missed secondary diagnoses and procedures and ensures compliance with all DRG mandates and reporting requirements; monitors Medicare and other DRG paid bulletins and manuals, and reviews the current Office of the Inspector General (OIG) work plans for DRG risk areas * Assists the HIM Coding Supervisor in performing data quality reviews on outpatient encounters to validate the ICD-10-CM, the Current Procedural Terminology (CPT), and the Healthcare Common Procedure Coding System (HCPCS) Level II code and modifier assignments; verifies Ambulatory Payment Classification (APC) group appropriateness; checks for missed secondary diagnoses and/or procedures; ensures compliance with all APC mandates and outpatient reporting requirements; monitors medical visit code selection against facility specific criteria for appropriateness; assists in the development of such criteria as needed * Monitors unbilled account reports for outstanding services or un-coded discharges to reduce accounts receivable days for inpatients and/or outpatients * Stays informed of transaction code sets, Health Insurance Portability and Accountability Act (HIPAA) requirements and other future issues impacting the coding function; keeps abreast of new technology in coding and abstracting software and other forms of automation * Demonstrates competency in the use of computer applications, particularly the coding and abstracting software and hardware currently in use by the Health Information Management division * Assists the HIM Coding Supervisor in performing periodic claim form reviews to check code transfer accuracy from the abstracting software and the charge master; may serve on a charge master maintenance committee * Complies statistics and prepares/maintains a variety of records and reports; finalizes attending physician attestations and obtains signatures; researches and locates missing data and records needed for coding and abstracting; retrieves files and records##### Additional Requirements**CONDITIONS OF EMPLOYMENT*** Natividad requires that all incumbents pass a pre-employment physical/medical assessment.* Natividad will conduct a thorough background and reference check process which includes a Department of Justice fingerprint check.* Employees who drive on County business to carry out job related duties must possess a valid CA Driver License for the class vehicle driven and clean driving record.* Employees must have and show their original Social Security Card and a valid CA Driver License or CA State ID prior to the first day of work.* Incumbents may be required to work all shifts, including nights, weekends, and holidays;* Incumbents may be required to work with potentially hazardous and infectious substances.##### Job NatureFull Time##### Educational Requirements**EXAMPLES OF EXPERIENCE/EDUCATION/TRAINING***Any combination of training, education and/or experience which
• J-18808-Ljbffr Natividad Medical Group

Job Tags

Similar Jobs