[Remote] HIM Coder I - HIM Financial - Full Time 8 Hour Days (Non-Exempt) (Non-Union)

Note: The job is a remote job and is open to candidates in USA. Veterans in Healthcare is seeking a HIM Coder I to work fully remote. The role involves accurately coding and abstracting medical records using various coding systems while ensuring compliance with federal and state coding regulations.

Responsibilities

• Outpatient Ancillary/Clinic Visit/Emergency Department coding of all diagnostic and procedural information from the medical records using ICD-10-CM, ICD-10-PCS, and CPT/HCPCS, and Modifier classification systems and abstracting patient information as established and required by official coding laws, regulations, rules, guidelines, and conventions
• Reviews the entire medical record; accurately classify and sequence diagnoses and procedures; ensure the capture of all documented conditions that coexist at the time of the encounter/visit, all medical necessity diagnoses, complications, co-morbidities, historical condition or family history that has an impact on current care or influences treatment, and all external causes of morbidity
• Enter patient information into inpatient and outpatient medical record databases (ClinTrac/HDM). Ensures accuracy and integrity of medical record abstracted UB-04 & OSHPD data elements prior to billing interface and claims submission
• Works cooperatively with HIM Coding Support and/or Clinical Documentation Improvement Specialist in obtaining documentation to complete medical records and ensure optimal and accurate assignment of diagnosis & procedure codes
• Assists in the correction of regulatory reports, such as OSHPD data, as requested
• Attendance, punctuality, and professionalism in all HIM Coding and work related activities
• Consistently assumes responsibility and displays reliability for completion of tasks, duties, communications and actions. Completes tasks accurately, legibly, and in a timely fashion
• Performs other duties as requested/assigned by Director, Manager, Supervisor, or designee
• Ability to achieve a minimum of 95% coding accuracy rate as determined by any internal or external review of coding and/or department quality review(s)
• Ability to achieve a minimum of 95% abstracting accuracy rate of UB-04 and OSHPD data elements as determined by any internal or external review of coding and/or department quality review(s)
• Assist in ensuring that all medical records contain information necessary for optimal and accurate coding and abstracting
• Recognizes education needs of based on monthly reviews and conducts self-improvement activities
• Ability to act as a resource to coding and hospital staff on coding issues and questions
• Ability to improve MS-DRG assignments specific to the documentation & coding of PDx, SecDx, CC/MCC, PPx, and SecPx in accordance with official coding laws, regulations, rules, guidelines, and conventions
• Ability to improve APR-DRG, SOI, and ROM assignments specific to the documentation & coding of PDx, SecDx, CC/MCC, PPx, and SecPx in accordance with official coding laws, regulations, rules, guidelines, and conventions
• Ability to improve APC/HCC assignments specific to medical necessity documentation & coding of PDx, SecDx, and CPT/HCPCS in accordance with official coding laws, regulations, rules, guidelines, and conventions
• Maintains at minimum, expected productivity standards (See HIM Practice Guidelines) and strives to maintain a steady level of productivity and provides consistent effort
• Works coding queues/task lists to ensure 95% of patient bills are dropped within 5 days after patient discharge/date of service
• Works coding queues/task lists to ensures the remaining 5% of patient bills are dropped within 2 weeks of discharge/date of service
• Assist other coders in performance of duties including answering questions and providing guidance, as necessary
• Assists Patient Financial Services (PFS), Patient Access, and other departments in addressing coding issues/questions and/or providing information so that an interim bill can be generated. Assists with physicians, physician office staff and hospital ancillary department staff with diagnostic or procedural coding issues/questions, as needed
• Assists in the monitoring unbilled accounts to ensure that the oldest records are coded and/or given priority
• Maintains AHIMA and or AAPC coding credential(s) specified in the job description
• Attend coding & CDI seminars, webinars, and in-services to maintain the required annual continued education units (CEU)
• Keep up-to-date and reviews ICD-10 Official Guidelines for Coding & Reporting, AHA Coding Clinic, and CPT Assistant to maintain knowledge of the principles of coding
• Keep up-to-date and reviews other professional journals and newsletters in a timely fashion to maintain knowledge of the principles of coding
• Consistently attend and actively participate in the daily huddles
• Consistently adhere to HIM policies and procedures as directed by HIM management
• Demonstrates an understanding of policies and procedures and priorities, seeking clarification as needed
• Participates in continuously assessing and improving departmental performance
• Ability to communicate changes to improve processes to the director, as needed
• Assists in department and section quality improvement activities and processes (i.e. Performance Improvement)
• Works and communicates in a positive manner with management and supervisory staff, medical staff, co-workers and other healthcare personnel
• Ability to communicate effectively intra-departmentally and inter-departmentally
• Ability to communicate effectively with external customers
• Provides timely follow-up with both written and verbal requests for information, including voice mail and email
• Working knowledge and efficient navigation of the Electronic Health Record (EHR): Cerner/Powerchart & Coding mPage
• Working knowledge, efficient navigation, & full use of 3M-CRS Encoder system; utilize to expedite coding process; utilize all references
• Knowledge & understanding of PFS system (PBAR) functionality and any interface with the coding abstracting system: ClinTrac
• Working knowledge, efficient navigation, & full use of ‘HDM/HRM/ARMS Core’ coding & abstracting software
• Working knowledge, efficient navigation, & full use of ‘3M 360 Encompass/CAC’
• Performs other duties as assigned

Skills

• High School or equivalent
• Specialized/technical training Successful completion of college courses in Medical Terminology, Anatomy & Physiology, and a certified coding course
• Successful completion of the hospital specific OP coding test – with a passing score of ≥70
• Experience in using a computerized coding & abstracting database software and an encoding/codefinder systems are required
• Demonstrates excellent verbal and written communication skills
• Organization/time management skills
• Able to function independently and as a member of a team
• Demonstrate excellent customer service behavior
• Certified Coding Specialist - CCS (AHIMA) or AHIMA Certified Coding Associate (CCA); or AHIMA Certified Coding Specialist - Physician (CCS-P); or AAPC Certified Professional Coder (CPC); or AAPC Certified Outpatient Coding (COC) or AAPC Certified Inpatient Coder (CIC)
• Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date
• Prior experience in ICD-9 & ICD-10 (combined) and CPT/HCPCS coding of Outpatient Ancillary/ED medical records in hospital and/or outpatient clinic preferred
• Working knowledge of CPT-4 and ICD-9CM coding and computerized billing systems such as IDX

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