Job Summary - Reviews and evaluates hospital inpatient medical record documentation to assign, sequence, edit and/or validate the appropriate ICD-10-CM and ICD-10- PCS codes. Performs coding and/or code/DRG 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):
• Assigns, sequences, validates, and/or edits codes/DRGs and abstracted data (e.g., physician, discharge disposition, query tracking) for inpatient records for multiple facilities using ICD-10-CM and ICD-10-PCS to include:
o Diagnosis description with appropriate 3-7 digit code assignment with corresponding Present On Admission (POA)
o Procedure description with appropriate 7 digit ICD-10-PCS code, date and surgeon
o Admitting Diagnosis
o Discharge disposition
o Where applicable, completes the coding portion of the IRF-PAI
• Maintains or exceeds established accuracy standards
• Maintains or exceeds established productivity standards
• Utilizes the complete patient medical record documentation in code/DRG assignment, validation, and/or editing of codes/DRGs
• Initiates, reviews, 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 III (CARS III) 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
• Follows all applicable coding guidance in assigning, sequencing, validation, and/or editing of codes/DRGs
• Meets all educational requirements as stated in current Company and HSC policy
• Practice and adhere to the "Code of Conduct" philosophy and "Mission and Value Statement"
• Other duties as assigned
KNOWLEDGE, SKILLS & ABILITIES
• Coding Technical Skills - ICD-10-CM, ICD-10-PCS, MS-DRGs, APR DRGs, and POA Assignment.
• Communication - communicates clearly and concisely.
• Customer Orientation - establishes and maintains long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.
• Analytical Skills - effective evaluation, synthesis and use of information gathered.
2 Coding Integrity Specialist (CIS) III Updated 3/01/2017
(previously Coder III)
• Initiative - independently takes prompt proactive steps toward problem resolution.
• Organization - establishing courses of action to ensure that work is completed efficiently; proactively prioritizes assignments and keen ability to multi-task.
• 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 (associates or bachelors) degree in HIM/HIT preferred.
Minimum 1 year of acute care hospital inpatient coding required, 3 years preferred.
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