Coding Specialist III – Inpatient Coder

St. Charles Health System

Introduction:

Title – Coding Specialist III – Inpatient coder         

Reports To Position – Coding Supervisor

Department – Health Information Management

Our Vision – Creating America’s healthiest community, together

Our Mission – In the spirit of love and compassion, better health, better care, better value

Our Values – Accountability, Caring and Teamwork

Departmental Summary: The Health Information Management Departments provide many services to our multi-hospital organization including: prepping, scanning and indexing, physician deficiency analysis, release of information, medical record maintenance, facility and profee coding, and medical transcription.

Position Overview: The Coding Specialist III at St. Charles Health System is responsible for coding/abstracting inpatient records. This position does not directly manage other caregivers, however may be asked to review and provide feedback on the work of other caregivers.

Job Description:

Essential Functions And Duties:

  • Read and interpret documents contained in the medical record to identify and code all relevant diagnoses and procedures by utilizing an encoder program, and following National and St. Charles Health System coding guidelines, Coding Clinic, and other appropriate coding references and tools to ensure proper code assignment.
  • Abstract medical record information in compliance with CMS requirements and St. Charles Health System abstracting procedures. Use available tools to check entries for accuracy. This may include data for clinical studies and quality management activities.
  • Select principal diagnoses and procedures in accordance with coding and UHDDS standards, CMS requirements, and prospective payment systems. Ensure that correct MS DRG is assigned for proper hospital reimbursement. Ensure that APR DRG severity of illness and risk of mortality values are accurate for reporting purposes.
  • Query physicians for clarification when conflicting or ambiguous information is present by following appropriate St. Charles Health System procedures.
  • Assign Present on Admission (POA) indicator accurately for each diagnoses coded, per CMS requirements published in official ICD-CM coding guidelines, and if uncertain, query the physician.
  • Accurately assign discharge disposition code, paying particular attention to post-transfer program DRGs for proper hospital reimbursement.
  • Plays an active role with the CDI (Clinical Documentation Improvement) team ensuring chart documentation meets the necessary requirements for accurate coding and reimbursement.
  • Maintain productivity and quality
  • Supports the vision, mission and values of the organization in all respects.
  • Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
  • Provides and maintains a safe environment for caregivers, patients and guests.
  • Conducts all activities with the highest standards of professionalism and Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
  • Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate.
  • May perform additional duties of similar complexity within the organization, as required or assigned.

Required Qualifications:

Licensure/Certification/Registration:

Required:  Must possess a valid Registered Health Information Technician (RHIT) certification or one or more of the following:   RHIA, CCA, CCS, CCS-P, CPC, CPC-H.  This position will require the caregiver to maintain required educational credits (CE) through AHIMA or AAPC.  Must have a valid Oregon driver’s license and ability to meet St. Charles Health System driving requirements.  Ability to travel to all St. Charles Health System worksites.

Preferred: AHIMA member

Experience:

Required:  3 years of hospital coding experience.

Preferred: Inpatient coding experience.  Familiarity with 3M encoder.  Familiarity with CAC (computer assisted coding)           

Personal Protective Equipment:

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

Additional Position Information:

Position Specific:

  • Knowledge of ICD-10 CM and PCS code assignment.
  • Knowledge of MS DRG and APR DRG reimbursement methodology.
  • Knowledge of Present on Admission “POA” assignment.
  • Knowledge of CPT-4 code assignment.
  • Knowledge of CCI and MN edits and APC grouping.
  • Knowledge of modifier and revenue code assignment.
  • Maintains professional knowledge by attending educational workshops, reviewing professional publications, participating in educational opportunities.

Communication/Interpersonal:

  • Demonstrates St. Charles Health System values of Accountability, Caring and Teamwork in every interaction.
  • Must have excellent communication skills and ability to interact with a diverse population and professionally represent St. Charles Health System.
  • Ability to effectively interact and communicate with all levels within St. Charles Health System and external customers/clients/potential employees.
  • Strong team working and collaborative skills.
  • Must have a positive attitude, ability to multi-task, pay close attention to details, and be able to act in a professional manner and demonstrate excellent public relations skills.
  • Ability to work in a fast paced work environment with frequent interruptions, maintaining the highest level of confidentiality at all times.

Organizational:

  • Ability to multi-task and work independently .
  • Attention to detail.
  • Excellent organizational skills, written and oral communication and customer service skills

Education Qualifications:

Required:  High School diploma or GED required.  Graduate of an AHIMA Accredited Health Information Technology program or certification in a self-study course from AHIMA or AAPC required.

Compensation/Benefits:

Healthcare, Dental, Vision, 403b

Instructions for Resume Submission:

Please submit your resume and cover letter on our online careers website for St. Charles Health System in Bend, OR.  You can search by the requisition number of R1002933.

Apply Online: https://stcharles.wd1.myworkdayjobs.com/External/job/Bend-OR/HIM—Coding-Specialist-III_R1002933