- Assigns International Classification of Diseases (ICD)-10-CM Clinical Modification (CM) and ICD-10-Procedure Coding System (PCS) codes creating diagnosis-related group (DRG) assignments. Abstracts pertinent information from patient records.
- Sequence the diagnosis and procedures using coding guidelines and optimizing the DRG as applicable.
- Addressing all edits, including but not limited to nosology, Exihauser, Patient Safety Indicators (PSI), hospital-acquired condition (HAC), and others as needed based on quality indicator.
- Apply reason/tracking code and rationale (if needed) in 3M as needed for DRG mismatches on Clinical Documentation Improvement (CDI) reviewed cases.
- Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous or unclear for coding purposes.
- Apply present on admission (POA) indicators on all inpatient charts.
- Keeps abreast of coding guidelines and reimbursement reporting requirements, new technology and procedures as well as CMS approved clinical trials. Brings identified concerns to the supervisor or department manager for resolution.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
- Data enters coded/abstracted information for DRG assignment into the HMH designated computer system.
- Review Case Management notes and assign discharge disposition based on the disposition indicated by CM or email leadership when not present and or conflicting.
- Identifying missing operative/path reports/or any pertinent procedures in patients records at the time of coding. Notifying Discharged not final billed (DNFB) of missing reports required for coding.
- Participate in ongoing coding educational webinars routinely and as needed.
- Participate as needed in external departments and/or Contract vendors review/educational sessions to comply with legal and procedural policies, optimize reimbursement and adhering to regulations.
- Review individually audited cases by third party companies and provide a rebuttal if needed.
- Other duties and/or projects as assigned.
- Adheres to HMH Organizational competencies and standards of behavior.
- High School diploma, general equivalency diploma (GED), and/or GED equivalent programs.
- Minimum of 3+ years of experience coding in an acute complex healthcare environment.
- Demonstrated expertise in Medical Terminology, Anatomy and Physiology, Pathophysiology, Pharmacology and inpatient coding.
- Encoder usage required with proficiency in computer skills.
- Excellent written and verbal communication skills.
- Proficient computer skills including but not limited to Microsoft Office and Google Suite platforms.
- Associate's level degree or higher in HIM, Allied health, or another related field.
- Certified Coding Specialist.
- Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT), or other Allied Health credential with inpatient coding experience.
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Inpatient Coder - Hackensack, United States - Hackensack Meridian Health
Description
Overview
Our team members are the heart of what makes us better.
At Hackensack MeridianHealth we help our patients live better, healthier lives — and we help one another to succeed. With a culture rooted in connection and collaboration, our employees are team members. Here, competitive benefits are just the beginning. It's also about how we support one another and how we show up for our community.
Together, we keep getting better - advancing our mission to transform healthcare and serve as a leader of positive change.
The Inpatient Coder assigns the principal diagnosis, comorbidities, complications and chronic conditions for Hackensack Meridian Health (HMH) Inpatient cases across the network to the highest specificity utilizing currently mandated coding systems in accordance with Centers for Medicare and Medicaid Services (CMS) and other coding compliance regulations.
This is a remote position.
Responsibilities
A day in the life of a Inpatient Coder at Hackensack Meridian Health includes:
Qualifications
Education, Knowledge, Skills and Abilities Required :
Education, Knowledge, Skills and Abilities Preferred :
Licenses and Certifications Required :
Licenses and Certifications Preferred :
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today
Job ID
Department HIM Inpatient Coding
Site HMH Hospitals Corporation
Job Location US-NJ-Hackensack
Position Type Full Time with Benefits
Standard Hours Per Week 40
Shift Day
Shift Hours 8:30 a.m. - 5:00 p.m.
Weekend Work No Weekends Required
On Call Work No On-Call Required
Holiday Work No Holidays Required
