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Coder - HIM

Company: Memorial Healthcare
Location: Owosso
Posted on: November 22, 2021

Job Description:

JOB SUMMARY: The Health Information Management (HIM) Coder impacts Memorial#s quality initiatives and reimbursement through the determination of the most accurate and optimal diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing. Under the supervisor of the Director of Health Information Management, this position is responsible for assigning diagnostic and procedural codes to patient charts of moderate to high complexity using ICD-9-CM, ICD-10-CM, CPT codes, HCPCS codes, creating APC, accurate MS-DRG group assignments accordance with coding rules and regulations. Abides by the Standards of Ethical Coding as set forth by AHIMA. Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care. PRIMARY JOB RESPONSIBILITIES: Maintains productivity levels as established by the Director of Health Information Management with a minimum 98% accuracy rate. Abstracts pertinent information from patient records, assigns ICD-9-CM, ICD-10-CM, HCPCS CPT-4 codes, creating APC or MS-DRG group assignments.# Performs review of the health record to ensure all codes are captured and sequenced appropriately. Seeks out missing information and creates complete records, including items such as disease and procedure codes, point of origin code, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons and anesthesiologists, and appropriate signatures/authorizations. Refers inconsistent patient treatment information/documentation to coding quality analysis, supervisor or individual department for clarification/additional information for accurate code assignment. Queries physicians and other healthcare providers when code assignments are not straight forward or documentation is inadequate, ambiguous, or unclear for coding and legal health record purposes. Keeps abreast of coding guidelines and reimbursement reporting requirements. Maintains appropriate, and demonstrates adequate use of, multiple software applications, including 3-M, various Meditech (Magic # Expanse) applications, scanning software, etc. Assures the patient#s health record is accurate, complete and represents a precise clinical picture of the specific encounter. Completes assigned tasks in appropriate timeframe and adjusts to increased workload. Problem solves and brings concerns to Supervisor/Director for resolution when appropriate. Actively contributes to the morale and teamwork of the staff and facility and always presenting a positive attitude and patient-minded vision, with patient satisfaction as the continuing goal. Follows established procedures for specific coding modalities, examples # concurrent coding, outpatient, inpatient, clinics and ancillary coding. Assists with training/orientation of new employees and students. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines. Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior. Other duties as assigned. JOB SPECIFICATIONS: EDUCATION Associate#s degree in Health Information Technology is required.# Minimum of successful completion of a registered coding program with AHIMA approval status, RHIA, RHIT, and CCS is required within one year of hire.# EXPERIENCE One year of Acute Care Hospital coding experience is required.# Knowledge of ICD-10-CM, HCPCS, CPT-4, codes, creating APC or MS-DRG group assignments, anatomy, physiology and pathophysiology.# Competency in the use of computer applications. ESSENTIAL PHYSICAL REQUIREMENTS/MOTOR SILLS Able to travel independently throughout all Memorial Healthcare facilities. Small motor skills required for operating modern computer, office, and telephone equipment as utilized by Memorial Healthcare (MHC). Able to sit for extended periods of time. ESSENTIAL MENTAL ABILITIES Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations. Ability to read and interpret a variety of documents including, but not limited to, policies operating instructions, white papers, regulations, rules and laws. Able to handle difficult and sensitive situations tactfully.## Able to follow instructions to learn work routines and problem solve.## Able to concentrate and maintain accuracy with frequent interruptions.# Must be self-motivated with the ability to work independently.# Must be able to code accurately and rapidly.# Ability to master basic math skills. ESSENTIAL TECHNICAL ABILITIES Proficiency using modern office, computer and telephone equipment as used by Memorial Healthcare. Motor skills required to page through hard copy and computerized records, open and close equipment, paper boxes, use typical medical office equipment. ESSENTIAL SENSORY REQUIREMENTS# Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals. Able to hear for work-related purposes. Ability to communicate through written and verbal communications receptively, expressively, with professionalism. INTERPERSONAL SKILLS# Ability to interact with co-works, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all time, physically, verbally and in all written and electronic communication. Required to remain calm when adversity is encountered. Open, honest, and tactful communication skills. Ability to work as a team member in all activities. Positive, cooperative and motived attitude. JOB SUMMARY: The Health Information Management (HIM) Coder impacts Memorial's quality initiatives and reimbursement through the determination of the most accurate and optimal diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing. Under the supervisor of the Director of Health Information Management, this position is responsible for assigning diagnostic and procedural codes to patient charts of moderate to high complexity using ICD-9-CM, ICD-10-CM, CPT codes, HCPCS codes, creating APC, accurate MS-DRG group assignments accordance with coding rules and regulations. Abides by the Standards of Ethical Coding as set forth by AHIMA. Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care. PRIMARY JOB RESPONSIBILITIES: * Maintains productivity levels as established by the Director of Health Information Management with a minimum 98% accuracy rate. * Abstracts pertinent information from patient records, assigns ICD-9-CM, ICD-10-CM, HCPCS CPT-4 codes, creating APC or MS-DRG group assignments. Performs review of the health record to ensure all codes are captured and sequenced appropriately. * Seeks out missing information and creates complete records, including items such as disease and procedure codes, point of origin code, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons and anesthesiologists, and appropriate signatures/authorizations. Refers inconsistent patient treatment information/documentation to coding quality analysis, supervisor or individual department for clarification/additional information for accurate code assignment. * Queries physicians and other healthcare providers when code assignments are not straight forward or documentation is inadequate, ambiguous, or unclear for coding and legal health record purposes. * Keeps abreast of coding guidelines and reimbursement reporting requirements. * Maintains appropriate, and demonstrates adequate use of, multiple software applications, including 3-M, various Meditech (Magic & Expanse) applications, scanning software, etc. * Assures the patient's health record is accurate, complete and represents a precise clinical picture of the specific encounter. * Completes assigned tasks in appropriate timeframe and adjusts to increased workload. * Problem solves and brings concerns to Supervisor/Director for resolution when appropriate. * Actively contributes to the morale and teamwork of the staff and facility and always presenting a positive attitude and patient-minded vision, with patient satisfaction as the continuing goal. * Follows established procedures for specific coding modalities, examples - concurrent coding, outpatient, inpatient, clinics and ancillary coding. * Assists with training/orientation of new employees and students. * Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines. * Demonstrates knowledge of and supports hospital mission, vision, value statements, standards, policies and procedures, operating instructions, confidentiality statements, corporate compliance plan, customer service standards, and the code of ethical behavior. * Other duties as assigned. JOB SPECIFICATIONS: EDUCATION * Associate's degree in Health Information Technology is required. * Minimum of successful completion of a registered coding program with AHIMA approval status, RHIA, RHIT, and CCS is required within one year of hire. EXPERIENCE * One year of Acute Care Hospital coding experience is required. * Knowledge of ICD-10-CM, HCPCS, CPT-4, codes, creating APC or MS-DRG group assignments, anatomy, physiology and pathophysiology. * Competency in the use of computer applications. ESSENTIAL PHYSICAL REQUIREMENTS/MOTOR SILLS * Able to travel independently throughout all Memorial Healthcare facilities. * Small motor skills required for operating modern computer, office, and telephone equipment as utilized by Memorial Healthcare (MHC). * Able to sit for extended periods of time. ESSENTIAL MENTAL ABILITIES * Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations. * Ability to read and interpret a variety of documents including, but not limited to, policies operating instructions, white papers, regulations, rules and laws. * Able to handle difficult and sensitive situations tactfully. * Able to follow instructions to learn work routines and problem solve. * Able to concentrate and maintain accuracy with frequent interruptions. * Must be self-motivated with the ability to work independently. * Must be able to code accurately and rapidly. * Ability to master basic math skills. ESSENTIAL TECHNICAL ABILITIES * Proficiency using modern office, computer and telephone equipment as used by Memorial Healthcare. * Motor skills required to page through hard copy and computerized records, open and close equipment, paper boxes, use typical medical office equipment. ESSENTIAL SENSORY REQUIREMENTS * Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals. * Able to hear for work-related purposes. * Ability to communicate through written and verbal communications receptively, expressively, with professionalism. INTERPERSONAL SKILLS * Ability to interact with co-works, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all time, physically, verbally and in all written and electronic communication. * Required to remain calm when adversity is encountered. * Open, honest, and tactful communication skills. * Ability to work as a team member in all activities. * Positive, cooperative and motived attitude.

Keywords: Memorial Healthcare, Flint , Coder - HIM, Other , Owosso, Michigan

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