Health Information Management Coding and Clinical Quality

The role of the Coder, Inpatient Level III is to interact extensively with the physician and others members of the healthcare team to facilitate the improvement in the overall quality, completeness and accuracy of medical record documentation. This position will support the appropriate clinical picture and level of severity of the patient while providing accurate and complete information that is utilized in the medical record and core measure abstraction and coding process to obtain appropriate reimbursement. This position will also be responsible for coordinating and providing education to all physicians and other clinicians related to compliant documentation responsibilities and coding and abstraction issues. This position will identify opportunities for documentation improvement to ensure accuracy and completeness of documentation used for measuring and reporting physician and hospital outcomes [e.g., patient safety indicators (PSI) and hospital-acquired conditions (HAC)]. The Coder, Inpatient Level III will collaborate as necessary with other disciplines to communicate these opportunities for referral to the appropriate performance improvement committee for resolution. This position will primarily review inpatient medical records using nationally recognized guidelines and assure accurate and complete documentation of diagnoses, procedures and DRG assignment. The Coder, Inpatient Level III will demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, case mix index, MS-DRG, APR-DRG, secondary diagnosis, risk-adjustment methodologies and impact of procedures on the final DRG.

QUALIFICATIONS

• EDUCATION: High school diploma required. Associate of Science degree in health information technology preferred. RHIA preferred. Successful completion of a college-based coding program or college-based coding certificate program preferred (AHIMA-approved preferred).
• LICENSE/CERTIFICATION: Certified Coding Specialist (CCS) required.
• Knowledge of core measures, HAC and AHRQ PSI/Harm Measures preferred.
• EXPERIENCE: Minimum 5 years of inpatient acute care coding (recent hands-on production) experience required. Proficiency in clinical and business applications preferred at time of hire. Incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

PERFORMANCE EXPECTATIONS
Demonstrates the technical competencies as established on the Assessment and Evaluation Tool.

WORK ENVIRONMENT
This active position requires the ability to work in a busy patient care area. Near visual acuity, long periods of visually examining documents and electronic files, and skilled use of multiple computer applications required. The Coder, Inpatient Level III works independently and autonomously with minimal supervision. Critical thinking and strong customer service skills required and ability to manage daily work duties accurately and efficiently

The essential functions for this position are listed on the Assessment and Evaluation Tool.