CODER III

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Facility: Presence Saint Joseph Hospital - ElginDepartment: PSJH HIM CODINGSchedule: Full-timeShift: Day shiftHours: Day ShiftLocation: Elgin, ILReq Number: 136226Job Details: Provide experienced level coding requiring coding education and experience consistent with the job qualifications and credentialed coder status. Responsible for the coding functions of inpatient patient record types.  Ensure ethical and accurate coding in accordance with all regulatory and system requirements and AHIMA Standards of Ethical Coding.     ESSENTIAL DUTIES AND RESPONSIBILITIES 1.     Reviews all diagnostic and clinical information contained in the medical record including dictated reports, diagnostic test results, progress notes, medication sheets, and nursing and ancillary department documentation, to determine if all care rendered is adequately documented for billing, data retrieval, and statistical purposes. Coder may perform any/all of the following types of coding; a.     Simple and complex inpatient records (obstetrics, non-surgical, surgical, inpatient psychiatric, etc.) b.    Inpatient rehabilitation records c.     Skilled nursing level records d.    Observation patient type records which include infusion charging e.     LTACH (Long Term Acute Care Hospital) records 2.     Ascertains the selection of the correct principal and secondary diagnoses and procedure codes according to the current International Classification of Disease, Clinical Modification (ICD-9-CM) coding guidelines, Physician's Current Procedural Terminology (CPT/HCPCS) guidelines, Uniform Hospital Discharge Data Set (UHDDS) requirements, and system policy and procedure. 3.     Coordinates clinical diagnostic and procedural documentation information with Clinical Documentation Specialist as appropriate. 4.     Determines proper sequencing of diagnosis and procedure codes according to established coding rules and regulations. 5.     Codes the medical record using an automated encoding system and coding manuals/references. 6.     Assigns correct DRG assignments as appropriate with the assistance of the encoding system. 7.     Contacts physicians or other health care professionals and hospital department representatives to obtain diagnostic information required for coding and billing of outpatient services. 8.     Abstracts required data elements from the medical record in accordance with established policies to create a complete and comprehensive database. 9.     Verifies accuracy of patient demographic data fields to ensure data integrity and proper reimbursement. 10.  Locates and utilizes the necessary resources to resolve coding questions as they arise during the performance of daily duties. 11.  Takes the initiative to retrieve clinical information from other sources when diagnostic information is not available in the medical record. 12.  Refers all incomplete or ambiguous cases to the coding supervisor/department manager for clarification and/or direction. 13.  Collaborates with the coding supervisor/department manager/director to manage the unbilled reports  by identifying and coding outstanding accounts older than 4 days from the date of service/discharge. 14.  Serves as a coding resource to other coding professionals within the department, in the absence of a coding supervisor. 15.  May assist physicians and various internal and external customers with queries regarding coding, sequencing, and DRG assignments as appropriate. 16.  Participates in coding audit activities. 17.  Maintains current knowledge of ICD-9-CM and CPT/HCPCS coding systems and other outpatient reimbursement methodologies by utilizing available coding educational resources and opportunities,   internal and external educational seminars, and in-service offerings. 18.  Attains and maintains proficiency in ICD-10-CM and ICD-10-PCS.  Understands new coding guidelines and participates in ongoing education and training.  Demonstrates proficiency prior to ICD-10 implementation date. 19.  Maintains coding credential/certification as appropriate. 20.  Meets established quality and productivity standards. 21.  Abides by Corporate Coding Compliance Plan. 22.  Adheres to department policies, procedures, and objectives. This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions.  Other duties may be assigned.EOE of Minorities/Females/Vets/Disability PI89938522