Certified Health Information Management Coder-Inpatient

Overview

POSITION DESCRIPTION

Natividad is currently seeking to fill one (1) permanent full time 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

Examples of Duties

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 Nature

Full Time

Educational Requirements

EXAMPLES OF EXPERIENCE/EDUCATION/TRAINING

Any combination of training, education and/or experience which provides the knowledge, skills and abilities and required conditions of employment listed above is qualifying. An example of a way these requirements might be acquired is: Experience: Two (2) years of experience equivalent to the class of Health Information Management Coder I in Monterey County.

and

Education: Completion of a community college, vocational school, or equivalent program in Medical Records Coding and Abstracting.

Experience Requirements

Job Location

Natividad Medical Center 1441 Constitution Blvd. Salinas

Salary

$39.39-$53.80/per hour

How to Apply

To complete a full application go to https://www.governmentjobs.com/careers/montereycounty/transferjobs and click apply to this position.

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