Certified Professional Coder, HIM

JOB SUMMARY:

The Coder reviews patient records and assigns codes (ICD-10-CM, ICD-10-PCS, CPT, HCPCS) for each diagnosis and procedure. The coder applies knowledge of medical terminology, disease processes, and pharmacology to ensure these codes accurately reflects the care provided to each patient.

RESPONSIBILITIES (ESSENTIAL FUNCTIONS):

• Accurately assigns and sequences codes (ICD-10-CM, ICD-10-PCS, CPT, HCPCS) for each patient encounter, following proper coding guidelines and legal requirements to ensure compliance with federal and state regulations.
• Abstracts required medical record information from patient records.
• Ensures correct diagnosis related group (DRG’s), all patient refined diagnosis related groups (APR DRG’s), and ambulatory payment classification (APC’s) are calculated.
• Queries providers when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
• Assigns and enters charges such as evaluation and management (E&M) levels, infusion/injections, observation hours, etc.
• Participate in continuing education activities to expand coding skills and stay abreast of changes in coding guidelines and reimbursement reporting requirements.
• Foster positive working relationships with Clinical Documentation Integrity (CDI), billing, and other pertinent positions at DRH Health.
• Identifies and reports discrepancies, potential quality concerns, and billing issues.
• Reviews records to ensure documentation in the record supports ordered services and meets medical necessity.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Association and adheres to official coding guidelines.
• Distribute confidential and sensitive information or documentation; Handle highly confidential records. Ensure records are safe and secure at all times.
• Regular attendance and punctuality for scheduled shifts. 
• Maintains professional and technical knowledge through continuing education opportunities including internal and external educational offerings.
• Utilization of assistive devices for lifting is mandatory.
• Must adhere to safety protocols at all times.
• Per DRH policy, all required conditions of employment must be met and maintained including required vaccinations.
• Implement DRH Standards of Behavior and exhibit behaviors consistent with DRH core values.
• Performs other related duties as assigned.

 

JOB REQUIREMENTS:

Minimum Qualifications: Outstanding communication and interpersonal skills including fluency in oral and written English. Basic computer skills including the ability to send/receive/email, navigate information technology associated with the position, and use Electronic Health Record information tools. Strong attention to detail with excellent organizational skills. Ability to adapt procedures, processes, tools, equipment, and techniques to accomplish the requirements of the position.

Education and/or Experience: High school diploma or equivalent required. Associate or bachelor's degree in Health Information Management is preferred. Previous work experience as a coder or strong training background in coding and reimbursement required. Prefer at least 3 years of experience in DRG and/or APC assignment.

Proven knowledge of CPT and ICD-10 coverage policies and coding guidelines. Demonstrated ability to read and interpret E&M notes, complex diagnostic study results, endoscopic, interventional and/or procedure operative notes. Ability to work independently and remain flexible to quickly adapt to urgent situations.

Certifications, Licenses, Registrations:

One of the following required:

• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Associate (CCA)
• Certified Coding Specialist (CCS)
• Certified Professional Coder (CPC)
• Certified Inpatient Coder (CIC)
• Certified Outpatient Coder (COC)

May have up to 12 months to obtain after date of hire or transfer. For those positions requiring travel, a current valid driver’s license and automobile liability insurance must be maintained.

Physical Demands: Team member is regularly required to communicate with and comprehend needs of others. Frequent use of hands including but not limited to handling records to prepare for scanning/uploading and keying information into the computer. Specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus. Must be able to examine work products prior to, during, and after scanning to ensure quality. Significant sitting; Some walking, standing, stooping, kneeling, crouching, and use of fine motor skills; Ability to reach, bend, stoop, push and/or pull, and lift up to 25 pounds.

Ability to read information on papers, computer screens, and other records; use a computer screen on a consistent basis; perform repetitive motions pertaining to the performance of job duties and the use of equipment; write, operate a computer keyboard, and finely manipulate small objects; concentrate and make efficient and effective decisions.

Work Environment: Generally, in an indoor setting; however, may participate in outside activities and events. The noise level in the work environment is usually mild. Use of office equipment includes but is not limited to telephone, computer, keyboard/mouse, printer, and copier. Wears protective clothing and/or personal protective equipment required by the work environment and/or governmental regulations and best practices as needed.  After an appropriate amount of onsite training, the team member may be allowed to work remotely on a scheduled, predetermined basis approved by the Director and as long as a current, approved telecommuting agreement is submitted to, and approved by, HR.

As a condition of employment, vaccinations are required per DRH Policy. Medical and Religious Exemptions are available upon request.