HIM Coder 2

Job Summary

Under the general supervision of Manager and direct supervision of Supervisor, following established policies, procedures and professional guidelines, the Coder 2 will:

• Perform a thorough review of medical record documentation to accurately assign diagnosis and procedure codes.

• Utilize the encoder system to sequence the codes assigned and calculate the corresponding MS-DRG/APR DRG/APC grouper.

• Abstract patient information into the computerized medical record and billing systems, ensuring the accuracy and integrity of the medical record data abstracted and encounter information prior to finalizing the encounter.

• Collaborate with the Clinical Documentation Improvement Team, Coding Team Coordinators and/or Supervisor to query for clarification of ambiguous documentation or, patient diagnostic and procedural information in the medical record.

• Be knowledgeable in the requirements of the industry with regard to Medicare and/or Managed care regulations, the International Classification of Diseases (ICD-9 and ICD-10-CM/PCS) and the Current Procedural Terminology (CPT) coding systems.

• Maintain quality and productivity standards established for the department and demonstrate proficiency in coding all types of moderate to high-complexity inpatient and outpatient records.

The Coder 2 may provide guidance and assistance to Coder I staff, Apprentices and clinical practice students orienting to the department. The Coder 2 is responsible for performing job duties in accordance with the mission, vision, and values of Tampa General Hospital.

Required:

• Possession of a national certification in health information management coding from the American Health Information Management Association (AHIMA), as a Certified Coding Specialist (CCS).

• Advanced-level knowledge of guidelines for the sequencing of diagnosis and procedure codes for appropriate classification systems.

• Advanced-level knowledge of anatomy, physiology, pathophysiology, pharmacology, and medical terminology to accurately translate medical record documentation into the appropriate classification system for reporting purposes.

• Experience in computerized encoding and abstracting software.

• Excellent professional verbal and written communication skills.

• At least two years of coding experience in an acute care setting, preferably a Trauma 1 teaching hospital or large healthcare delivery system.

• Ability to multi-task and work independently.

• Ability to efficiently complete work assignments and interact with coding leadership team to review and discuss documentation, coding and reimbursement issues.