Saint Peter's Healthcare System

Inpatient Hospital Certified Coder

New Brunswick, NJ, US

Remote
Full-time
9 months ago
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Summary

Inpatient Hospital Certified Coder 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

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