Coder Senior - Medical Records Services - Full Time - Days
- Req #: 9306
- Address: 2100 Sherman Ave
- City, State: Norwood, OH
- Zip: 45212
- Type: Full time
- Shift: Day
Job Description
Interprets clinical documentation/records of complex outpatient and/or basic inpatient cases to ensure all diagnoses and procedures are documented and coded.
Responsibilities
• Interprets clinical documentation/records to ensure all diagnosis and procedure documentation is coded.
• Applies regulatory and facility guidelines while coding.
• Code clinical documentation with an accuracy rate consistent with the hospital quality program.
• Minimal supervision with wide latitude for independent judgment. Advanced problem-solving responsibilities while working under defined guidelines.
Abstract clinical information from the medical record into the clinical information system with an accuracy rate consistent with the hospital abstracting quality program. The inpatient and outpatient abstracting policy should be referenced for specific on TCH abstracting practices.
• Facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation.
• Concurrently reviews clinical information in medical records and obtains appropriate clinical documentation by interacting with physicians and patient care services. This is necessary to ensure that the clinical documentation reflects the level of service rendered and the patient's severity and acuity of care is reflected.
• Interacts with physicians by written queries.
• Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in the medical record.
• Escalates unresolved queries to coding management.
• Interprets health record content to ensure that all diagnoses and procedures assigned are supported by physician documentation.
Coder will code and abstract medical records at a productivity rate that is consistent with the hospital productivity program.
Participates in continued quality improvement opportunities
Other duties as assigned
Qualifications
KNOWLEDGE AND SKILLS:
EDUCATION: Associate or Bachelor Degree in HIM or related field preferred. Or 7+ years of hospital coding experience.
Holds more than one credential including RHIA or RHIT with CCS, or one credential with 3 years' experience. Skills assessment required determining competency level of coding skills. Outcome determines placement in intermediate to advance level.
YEARS OF EXPERIENCE: 3 or more years of experience.
REQUIRED SKILLS AND KNOWLEDGE:
KNOWLEDGE AND SKILLS:
Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.
EDUCATION: non credentialed coder or CCA or CPC with some coding experience strongly preferred. Skills assessment required determining competency level of coding skills and outcome determines placement in intermediate to advance level.
YEARS OF EXPERIENCE: See below.
REQUIRED SKILLS AND KNOWLEDGE:
Criteria:
Skills*:
Coder Level I:
Basic outpatient cases one type with simple diagnoses and procedures.
Coder Level II:
Can code 2 types of basic outpatient cases such as OP and ED or OP and Ambulatory with outpatient procedures/or inpatient cases. Contributes to team objectives. Moderate skills with high level of proficiency.
Coder Level III:
Complex outpatient cases and/or inpatient cases.
Coder Level IV:
Complex skills with high level of proficiency in ALL facility coding cases. Proactive to contribute to meeting team objectives, including training other coders.
Education:
Coder Level I:
Successful completion of some coursework or formal education in:
Coder Level II:
Successful completion of coursework or formal education in:
Coder Level III:
Successful completion of advanced coursework or formal education in:
Coder Level IV:
Successful completion of advanced coursework or formal education in:
*Each increase in levels assumes the ability to code at the previous skill level.
LICENSES REGISTRATIONS &/or CERTIFICATIONS :
RHIA or RHIT with CCS ; or 1 credential with 3 years of experience.
Other Credentials Required or Preferred: NONE
Interprets clinical documentation/records of complex outpatient and/or basic inpatient cases to ensure all diagnoses and procedures are documented and coded.
Responsibilities
• Interprets clinical documentation/records to ensure all diagnosis and procedure documentation is coded.
• Applies regulatory and facility guidelines while coding.
• Code clinical documentation with an accuracy rate consistent with the hospital quality program.
• Minimal supervision with wide latitude for independent judgment. Advanced problem-solving responsibilities while working under defined guidelines.
Abstract clinical information from the medical record into the clinical information system with an accuracy rate consistent with the hospital abstracting quality program. The inpatient and outpatient abstracting policy should be referenced for specific on TCH abstracting practices.
• Facilitates improvement in the overall quality, completeness, and accuracy of medical record documentation.
• Concurrently reviews clinical information in medical records and obtains appropriate clinical documentation by interacting with physicians and patient care services. This is necessary to ensure that the clinical documentation reflects the level of service rendered and the patient's severity and acuity of care is reflected.
• Interacts with physicians by written queries.
• Conducts follow-up reviews of clinical documentation to ensure issues discussed and clarified with the physician have been documented in the medical record.
• Escalates unresolved queries to coding management.
• Interprets health record content to ensure that all diagnoses and procedures assigned are supported by physician documentation.
Coder will code and abstract medical records at a productivity rate that is consistent with the hospital productivity program.
Participates in continued quality improvement opportunities
Other duties as assigned
Qualifications
KNOWLEDGE AND SKILLS:
EDUCATION: Associate or Bachelor Degree in HIM or related field preferred. Or 7+ years of hospital coding experience.
Holds more than one credential including RHIA or RHIT with CCS, or one credential with 3 years' experience. Skills assessment required determining competency level of coding skills. Outcome determines placement in intermediate to advance level.
YEARS OF EXPERIENCE: 3 or more years of experience.
REQUIRED SKILLS AND KNOWLEDGE:
KNOWLEDGE AND SKILLS:
Please describe any specialized knowledge or skills, which are REQUIRED to perform the position duties. Do not personalize the job description, credentials, or knowledge and skills based on the current associate. List any special education required for this position.
EDUCATION: non credentialed coder or CCA or CPC with some coding experience strongly preferred. Skills assessment required determining competency level of coding skills and outcome determines placement in intermediate to advance level.
YEARS OF EXPERIENCE: See below.
REQUIRED SKILLS AND KNOWLEDGE:
Criteria:
Skills*:
Coder Level I:
Basic outpatient cases one type with simple diagnoses and procedures.
- outpatient diagnostic testing
Coder Level II:
Can code 2 types of basic outpatient cases such as OP and ED or OP and Ambulatory with outpatient procedures/or inpatient cases. Contributes to team objectives. Moderate skills with high level of proficiency.
Coder Level III:
Complex outpatient cases and/or inpatient cases.
- Same day surgeries
- Endoscopy
- Cardiac Cath
- Interventional Radiology
- Proactive to contribute to meeting team objectives. Complex skills with high level of proficiency.
Coder Level IV:
Complex skills with high level of proficiency in ALL facility coding cases. Proactive to contribute to meeting team objectives, including training other coders.
Education:
Coder Level I:
Successful completion of some coursework or formal education in:
- ICD-10-CM/PCS & CPT
- Disease process
- Medical terminology
Coder Level II:
Successful completion of coursework or formal education in:
- ICD-10-CM/PCS & CPT
- Disease process
- Medical terminology
Coder Level III:
Successful completion of advanced coursework or formal education in:
- ICD-10-CM/PCS & CPT
- Disease process
- Medical terminology
Coder Level IV:
Successful completion of advanced coursework or formal education in:
- ICD-10-CM/PCS & CPT
- Disease process
- Medical terminology
*Each increase in levels assumes the ability to code at the previous skill level.
LICENSES REGISTRATIONS &/or CERTIFICATIONS :
RHIA or RHIT with CCS ; or 1 credential with 3 years of experience.
Other Credentials Required or Preferred: NONE
