Inpatient Coder

AVEM BUSINESS SOLUTIONS LLC•Oklahoma City, OK

4d•Remote

About The Position

JOB PURPOSE: To abstract and code compliantly, accurately and completely as well as group each account to the appropriate DRG to facilitate data quality and ensure accurate and timely reimbursement. Verifies reviews, analyzes, and abstracts medical information; researches missing medical information; assigns accurate codes; appropriately queries physicians when required; elevates documentation issues to management; ensures valid orders are on the record prior to coding; communicates with HIM Director regarding obstacles with orders, charges, physician documentation. Demonstrates proficiency in the coding and grouping of inpatient accounts. ESSENTIAL FUNCTIONS INCLUDE BUT NOT LIMITED TO: Assures data quality by capturing codes and data while complying with NCCI, while maintaining a 95% or higher accuracy rate as validated by audit. Demonstrates consistent and efficient performance by coding a minimum of 3.5 to 4 inpatient accounts per hour. Queries physicians as necessary to clarify missing, ambiguous, incomplete or conflicting documentation in the medical record in order to facilitate complete, accurate and consistent coding. Notifies HIM Director and Manager of Revenue Cycle when the admission order is missing or not signed prior to discharge. Accurately abstracts information from the medical record into the abstracting module. Demonstrates competencies with software systems in use for the HIM coding staff. Collaborates with Director on Coding Queries. Serves as a resource to other coders. Manages time and workload with understanding of the relationship between coding accuracy, timeliness and deadlines. Keeps current of all changes in coding by reading all new Coding Clinics and CPT Assistants annually. Complete a minimum of 10 hours of formal education and 10 hours of informal education (reading coding clinics and CPT Assistant), which can be turned to formal by taking the quiz on the back and submitting for credit. Performs additional responsibility as directed. BEHAVIORAL STANDARDS The individual must support the mission, vision, and goals of Avem Health Partners and serve as a role model within the company. Exhibit positive customer service behavior in every day work interactions. Demonstrate a courteous and respectful attitude to internal workforce and external customers. Communicate accurately and appropriately. Handle difficult situations in a discreet and professional manner. Hold self-accountable for professional practice. Participate in performance improvement activities utilizing principles to support and improve departmental goals. Demonstrate knowledge of unit goals and is active in committees and projects to achieve these goals. Keep current with literature regarding changing practices, interventions and best practices. Assume responsibility for seeking out educational and professional opportunities for personal learning needs and growth as well as meeting mandatory education requirements. Act as a preceptor as requested. Demonstrate excellent work attendance and actively participate in a variety of meetings and training sessions as required. Adhere to the Avem Health Partners Code of Conduct and Standards of Behavior. Complies with established policies and procedures and all health and safety requirements.

Requirements

Graduate of an AHIMA coding program, RHIT or RHIA program
Minimum 3-5 years inpatient coding experience preferred or equivalent combination of education and experience
High level of competence in inpatient coding, DRG grouping, ICD-10 diagnostic and procedural code assignment
Competency related to coding of outpatient record types
Passing score on company coding test
Possesses basic knowledge of HIM principles and department functions
Possesses advanced knowledge of ICD—10CM and ICD-10PCS coding rules and conventions
Possesses advanced knowledge of medical terminology, anatomy and physiology, disease processes and pharmacology
Ability to read and analyze all aspects of medical record documentation for accurate and complete coding
Possesses a thorough knowledge of the encoder system
Experienced and highly knowledgeable in the DRG/MSDRG grouping system
Ability to abstract information from the medical record for indices and statistical reports
Excellent PC and software utilization skills
Ability to work independently
CCS, CPC, RHIT or RHIA credentialed by American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC)
This job requires visual abilities and auditory abilities, must be intact to perform duties
Must be able to perform repetitive tasks/motions

Nice To Haves

AS or BS degree preferred

Responsibilities

Abstract and code compliantly, accurately and completely
Group each account to the appropriate DRG
Verify, review, analyze, and abstract medical information
Research missing medical information
Assign accurate codes
Query physicians when required
Elevate documentation issues to management
Ensure valid orders are on the record prior to coding
Communicate with HIM Director regarding obstacles with orders, charges, physician documentation
Assure data quality by capturing codes and data while complying with NCCI, while maintaining a 95% or higher accuracy rate as validated by audit
Demonstrate consistent and efficient performance by coding a minimum of 3.5 to 4 inpatient accounts per hour
Notify HIM Director and Manager of Revenue Cycle when the admission order is missing or not signed prior to discharge
Accurately abstract information from the medical record into the abstracting module
Demonstrate competencies with software systems in use for the HIM coding staff
Collaborate with Director on Coding Queries
Serve as a resource to other coders
Manage time and workload with understanding of the relationship between coding accuracy, timeliness and deadlines
Keep current of all changes in coding by reading all new Coding Clinics and CPT Assistants annually
Complete a minimum of 10 hours of formal education and 10 hours of informal education (reading coding clinics and CPT Assistant), which can be turned to formal by taking the quiz on the back and submitting for credit
Perform additional responsibility as directed