Location: Orlando,FL, USA
Responsible for performing, developing, and implementing hospital coding services to ensure the diagnostic and procedure codes are assigned accurately to inpatient and outpatient encounters based upon documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines.
Responsibilities:Essential Functions ? Interacts and communicates effectively with coders, physicians, physician extenders, physician offices and members of the coding and management team ? Collaborates with manager and other members of the Revenue Management Team to review all necessary patient records for accurate coding for best practice ? Review and audit medical records to ensure quality of work and specificity of diagnoses and procedures to ensure appropriate and optical reimbursement ? Responds promptly to internal and external requests to provide feedback on coding related issues. ? Participates and provides good feedback during coding section meetings and coding education in services as well as takes initiative to assist others and shares knowledge with the appropriate stakeholders. ? Maintains and achieves the highest standards of coding quality by assigning accurate/ICD-10-CM/ICD-10-PCS codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines. ? Maintains and achieves department standards of abstracting quality by reviewing accurate discharge disposition, to achieve the highest quality of entered data. ? Reviews medical record documentation and abstracts data into Electronic Health Record (EHR) to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions, and procedures. Utilizes all tools/ resources for accuracy. ? Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA), American Academy of Professional Coders (AAPC), and adheres to official guidelines. ? Collaborates with Clinical Document Excellence (CDE), Quality Management and other departments to determine appropriate DRG assignment for compliance and reimbursement purposes ? Attends departmental and interdepartmental meetings as required ? Utilizes resource material available in department to support coding practices ? Assist in coding in any Inpatient and/or Outpatient cases as needed ? Takes an active role in developing and presenting educational materials to different stake holders ? Serves as a preceptor to new coders ? Maintains reasonably regular, punctual attendance consistent with Orlando Health policies, the ADA, FMLA and other federal, state, and local standards ? Maintains compliance with all Orlando Health policies and procedures
Other Related Functions ? Develops and updates internal departmental processes ? Assumes the responsibility for professional growth and development through educational programs, research, etc. ? Maintains certification status ? Performs other related duties as assigned ? Maintains 95% or above accuracy rate
Qualifications:Education/Training ? Completion of coding certificate program or Associates or bachelors degree in Health Information Management ? Computer literacy, knowledge of Anatomy, Physiology and Medical Terminology required ? Thorough knowledge of official coding guidelines as per AMA, AHA, and CMS. ? Coding skills test of 90% or better
? Advanced level knowledge of anatomy, physiology, pathophysiology, pharmacology, and medical terminology to accurately translate medical record documentation into the appropriate classification system for reporting purposes
Licensure/Certification One of the following national certifications: ? Certified Professional Coder (CPC) through the American Academy of Professional Coders ? Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) through AHIMA
Experience Four (4) years of relevant hospital inpatient and/or outpatient coding experience.
Inpatient Liaison Hospital inpatient. - Advanced level of knowledge of sequencing guidelines for the sequencing of diagnosis and procedure codes for appropriate classification systems with knowledge of ICD-10, ICD-10 PCS, MS-DRG and APR-DRG. - Level one (1) Trauma hospital experience (Preferred) Outpatient Liaison Hospital outpatient.- Advanced level of knowledge of experience with ICD-10 and CPT coding in the radiation oncology field is required. Radiation Oncology Liaison Hospital and Outpatient - Advanced level of knowledge of experience with ICD-10 and CPT coding in the radiation oncology field is required. - The Radiation Oncology Coder is responsible for ensuring all services rendered are captured timely, coded accurately, and meet documentation requirements when processed through the EMR and Billing Systems.