Job Summary - Reviews and evaluates hospital outpatient medical record documentation to assign, sequence, edit and/or validate the appropriate ICD-10-CM and HCPCS/CPT codes. Performs coding and/or code validation across multiple entities. Applies all appropriate coding guidelines and criteria for code selections. Adheres to Company and HSC Coding Compliance policies and procedures for the assignment of complete, accurate, timely, and consistent codes for diagnoses and procedures.
Supervisor - Coding Manager
Supervises - N/A
Duties (included but not limited to):
• Using, ICD-10-CM and/or HCPCS/CPT, primarily assigns, validates, and/or edits codes the following patient types:
o Same day surgery (SDC)
o Observation (OBV)
o Wound Care
o Outpatient Cardiac Cath
• As needed, may also assign, validate, and/or edit codes for the following patient types:
o Emergency department (ED)
o Recurring (RCR)
o Clinical (CLI) records, and/or
o Provider Office Visit (POV)
• Assigns, validates, and/or edits procedure categories, modifiers (when applicable)
• Maintains or exceeds established productivity standards
• Maintains or exceeds established accuracy standards
• Initiates, validates, and/or edits physician queries in compliance with Company and HSC policy where appropriate
• As needed, may periodically be asked to perform Coding Account Resolution Specialist II and/or I (CARS II and I) duties
• Reviews all official data quality standards, coding guidelines, Company policies and procedures, and clinical/medical resources to assure coding knowledge and skills remain current
• Utilizes the complete medical record documentation in code assignment, validation, and/or editing of codes
• Follows all applicable coding guidance in assigning, sequencing, validation, and/or editing of codes
• Meets all educational requirements as stated in current Company and HSC policy
• Practices and adheres to the "Code of Conduct" philosophy and "Mission and Value Statement"
• Other duties as assigned
KNOWLEDGE, SKILLS & ABILITIES
• Coding Technical Skills- ICD-10-CM, HCPCS/CPT-4, and APCs.
• Analytical Skills - effective evaluation, synthesis and use of information gathered.
• Organization - establishing courses of action to ensure that work is completed efficiently; proactively prioritizes assignments and keen ability to multi-task.
• Communication - communicates clearly and concisely.
• Customer Orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.
• Policies & Procedures - articulates knowledge and understanding of organizational policies, procedures and systems.
• PC Skills - demonstrates proficiency in Microsoft Office applications and others as required.
• Quality Orientation - accomplishing tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
• Work Independently - is self-supporting; not needing to rely on others to complete a job.
High School graduate or GED equivalent required, undergraduate (associate or bachelors) degree in HIM/HIT preferred.
One (1) year acute care observation and/or same day surgery hospital outpatient coding experience required.
CERTIFICATE/LICENSE - RHIT, RHIA or CCS preferred.
PHYSICAL DEMANDS/WORKING CONDITIONS
Requires prolonged sitting/standing, some bending, stooping, walking and stretching. Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator and other office equipment. Requires normal range of hearing and eyesight to record, prepare and communicate appropriate reports or other information. Requires lifting papers/boxes and pushing/pulling up to 25 pounds occasionally. Work is performed in an office environment or hospital setting. Work may be stressful at times. Contact may involve dealing with angry or upset people. Staff must remain flexible and available to provide staffing assistance for any/all disaster or emergency situations.
A little about us:
HCA is the nation’s leading private provider of healthcare services. Comprised of locally managed facilities which include 230,000 employees at over 160 hospitals, over 120 surgery centers and 100 urgent care facilities in 20 states and the United Kingdom