Clinical Coder

Johnson County Hospital•Tecumseh, NE

13d•Onsite

About The Position

Accountable for conversion of diagnoses and treatment procedures into codes using an international classification of diseases. Requires skill in sequencing of diagnosis/procedures. Ensures that records are coded in an accurate and timely manner for data retrieval, analysis, and claims processing.

Requirements

Medical Terminology, Anatomy & Physiology Coursework.
Technical skills and proficiency with spreadsheets, databases and EHR software, communication, customer service, time management, critical thinking and troubleshooting skills.
Understanding of data gathering, structuring, categorization and manipulation.
Ability to research billing and coding regulations and resources.
Good business communication skills, professional telephone techniques and patient relations.
Able to treat others with respect and consideration.
Requires professionalism.
Be an active team member and support each member and the team as a whole.

Nice To Haves

Successful completion of coding certificate program in a program with AHIMA approval status; RHIA, RHIT, CCS, CCS-P, CCA certification status preferred.
Prefer work experience as a coder or strong training background in coding and reimbursement.

Responsibilities

Knowledgeable of all charting and coding requirements, including Acute care, Swingbed, and outpatient services.
Ensures that records are coded accurately and timely, within four (4) days of discharge, excluding weekends and holidays.
Reviews medical record thoroughly to ascertain all diagnoses/procedures.
Abstracts pertinent information from patient records.
Assigns ICD-10-CM or HCPCS codes in accordance to the ICD-10-CM/CPT coding principles and the Coding Manual.
Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
Contacts responsible provider in a professional, tactful manner.
Coder's diagnoses and procedures on clinical summary agree with physician's preference.
Logs diagnoses, procedures, and other abstracting data for registers according to State reporting guidelines.
Refers to HIM Coding Lead or HIM manager if there is a question regarding the diagnoses/codes.
Keeps abreast of coding guidelines and reimbursement reporting requirements.
Brings identified concerns to 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.
Demonstrates proficiency in coding and abstracting software/encoder.
Utilizes coding references available.
Reviews coding periodicals within seven (7) days of receipt.
Analyzes records for completeness and accuracy according to department and hospital policy and procedures for physician and nursing completion.
Notifies physicians and nursing departments of delinquent or deficient medical records.
Follows up on incomplete records within one week of notification.
Runs deficiency analysis reports and other abstracting as requested by HIM manager.
Performs final qualitative chart analysis to ensure all required documentation has been completed.
Performs quantitative chart analysis to ensure accuracy of documentation pertinent to encounter, and accurate record preparation for coding.
Collaborates with Admission staff, Billing staff, Coding Lead and HIM Director as necessary for patient accounts requiring attention for timely and optimal hospital payment.
Performs quality improvement functions through data collection and documentation review.
The HIM Coder will understand and demonstrate compliance with HIPAA regulations and will comply with all JCH policies and procedures.
The HIM Coder will carry out any other responsibilities deemed necessary by the HIM Director.