Clinical Document-Coding Mgmt

The Inpatient Hospital Certified Coder will:

CODING:

• Utilizing judgment gained from coding experience, assign appropriate codes for all applicable diagnosis and procedures, concurrently on patient units.
• Code and abstract.
• Independently manage daily workflow on assigned unit(s).
• Validate correct patient types (observation vs. inpatient) by checking physician order.
• Reconcile HIM discharged not final billed report (DNFB) to ensure all discharged charts are accounted for on his/her assigned units.
• Notify coding supervisor, director, clinical documentation; assistant manager HIM; nursing manager, and clinical documentation specialist covering unit regarding missing patient records.
• On discharge reconcile with clinical documentation specialist nurse, finalize coding, abstract, accept final DRG for billing.
• Deliver discharged charts to the Health Information Management Department.
• Complete concurrent admission reviews within 48 hours of patient admission (excluding weekend and holidays).
• Ensure timely follow-up reviews in accordance with unit review guidelines.
• Collaborate with clinical documentation nursing specialists by identifying conflicting, ambiguous, or incomplete information in the medical record.
• Participate in hospital performance improvement activities as requested.
• Ensure that hospital acquired conditions (HAC), and complications are validated by clinical documentation nursing specialists, and/or performance improvement department.
• Query physicians for all questions relating to diagnostic and procedural information in the medical record.
• Notify coding supervisor all issues that will delay billing.
  
  

MENTORING and TRAINING: Under the direction of the Director and/or coding supervisor, Clinical Documentation & Coding Management:

• Assist with training of newly hired coders to include, but not limited to CPT, HCPCS and/or ICD coding.
• Train fellow coders on use of computer systems including, but not limited to, McKesson STAR and 3M.
• Respond to questions and assists fellow coders with code assignments as needed.
  
  

Requirements:

• Knowledge of coding systems, medical terminology, anatomy and physiology required.
• A minimum of five (5) years of inpatient coding experience required.
• Strong interpersonal and decision-making skills required.
  
  

Remote!

In-Hospital Experience Required!

Grade 123