The role of the Coder – Inpatient, Level III is to interact extensively with the physician and other members of the healthcare team to facilitate the improvement in the overall quality, completeness and accuracy of medical record documentation. This will support the appropriate clinical picture and level of severity of the patient while providing accurate and complete information that is then utilized in the medical record, 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 and hospital acquired conditions).
The Coder – Inpatient, Level III will collaborate with other disciplines, as necessary, 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 to assure accurate and complete documentation of diagnoses and 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 diagnoses, risk-adjustment methodologies and impact of procedures on the final DRG .
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 of 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.
Demonstrates the technical competencies as established on the Assessment and Evaluation Tool.
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 health data integrity specialist works independently and autonomously with minimal supervision. Critical thinking and strong customer services skills required and manage daily work duties accurately and efficiently
The essential functions for this position are listed on the Assessment and Evaluation Tool.
AtlantiCare is an equal opportunity employer that takes affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status or disability.