Job Description

JOB PURPOSE: To abstract and code compliantly, accurately and completely as well as group each account to the appropriate DRG to facilitate data quality and ensure accurate and timely reimbursement. Verifies reviews, analyzes, and abstracts medical information; researches missing medical information; assigns accurate codes; appropriately queries physicians when required; elevates documentation issues to management; ensures valid orders are on the record prior to coding; communicates with HIM Director regarding obstacles with orders, charges, physician documentation. Demonstrates proficiency in the coding and grouping of inpatient accounts.

ESSENTIAL FUNCTIONS INCLUDE BUT NOT LIMITED TO:

• Assures data quality by capturing codes and data while complying with NCCI, while maintaining a 95% or higher accuracy rate as validated by audit.
• Demonstrates consistent and efficient performance by coding a minimum of 3.5 to 4 inpatient accounts per hour.
• Queries physicians as necessary to clarify missing, ambiguous, incomplete or conflicting documentation in the medical record in order to facilitate complete, accurate and consistent coding.
• Notifies HIM Director and Manager of Revenue Cycle when the admission order is missing or not signed prior to discharge.
• Accurately abstracts information from the medical record into the abstracting module.
• Demonstrates competencies with software systems in use for the HIM coding staff.
• Collaborates with Director on Coding Queries.
• Serves as a resource to other coders.
• Manages time and workload with understanding of the relationship between coding accuracy, timeliness and deadlines.
• Keeps current of all changes in coding by reading all new Coding Clinics and CPT Assistants annually.
• Complete a minimum of 10 hours of formal education and 10 hours of informal education (reading coding clinics and CPT Assistant), which can be turned to formal by taking the quiz on the back and submitting for credit.
• Performs additional responsibility as directed.

BEHAVIORAL STANDARDS

• The individual must support the mission, vision, and goals of Avem Health Partners and serve as a role model within the company.
• Exhibit positive customer service behavior in every day work interactions.
• Demonstrate a courteous and respectful attitude to internal workforce and external customers.
• Communicate accurately and appropriately.
• Handle difficult situations in a discreet and professional manner.
• Hold self-accountable for professional practice.
• Participate in performance improvement activities utilizing principles to support and improve departmental goals.
• Demonstrate knowledge of unit goals and is active in committees and projects to achieve these goals.
• Keep current with literature regarding changing practices, interventions and best practices.
• Assume responsibility for seeking out educational and professional opportunities for personal learning needs and growth as well as meeting mandatory education requirements.
• Act as a preceptor as requested.
• Demonstrate excellent work attendance and actively participate in a variety of meetings and training sessions as required.
• Adhere to the Avem Health Partners Code of Conduct and Standards of Behavior. Complies with established policies and procedures and all health and safety requirements.

EDUCATION/QUALIFICATIONS:

• Graduate of an AHIMA coding program, RHIT or RHIA program.
• AS or BS degree preferred.
• Minimum 3-5 years inpatient coding experience preferred or equivalent combination of education and experience.
• High level of competence in inpatient coding, DRG grouping, ICD-10 diagnostic and procedural code assignment.
• Competency related to coding of outpatient record types.
• Passing score on company coding test.
• Possesses basic knowledge of HIM principles and department functions.
• Possesses advanced knowledge of ICD10CM and ICD-10PCS coding rules and conventions.
• Possesses advanced knowledge of medical terminology, anatomy and physiology, disease processes and pharmacology.
• Ability to read and analyze all aspects of medical record documentation for accurate and complete coding.
• Possesses a thorough knowledge of the encoder system.
• Experienced and highly knowledgeable in the DRG/MSDRG grouping system.
• Ability to abstract information from the medical record for indices and statistical reports.
• Excellent PC and software utilization skills.
• Ability to work independently.

CERTIFICATION/LICENSURE:

• CCS, CPC, RHIT or RHIA credentialed by American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC)

PHYSICAL REQUIREMENTS:

• To perform this job successfully, an individual must be able to perform each essential job duty satisfactorily. The requirements listed are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. Such accommodations must be requested by the employee/applicant to be considered.
• This job requires visual abilities and auditory abilities, must be intact to perform duties.
• Must be able to perform repetitive tasks/motions.

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