HIM Coder 3

Job Summary

Under the general supervision of Manager and direct supervision of Supervisor, following established policies, procedures and professional guidelines, the Coder 3 will:

• Perform a thorough review of medical record documentation to accurately assign diagnosis and procedure codes for complex inpatient and outpatient records in addition to auditing and analysis of coding related activities.

• 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.

• Work with a multidisciplinary team to review and discuss documentation, coding and reimbursement issues of patients and identify documentation needs for medical staff and other health care providers, providing education as needed.

• 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 high-complexity records.

The Coder 3 will, as requested, assist with mentoring or training newly on-boarded Coders, Apprentices, and clinical practice students orienting to the department. The nature of this work may require that the Coder III work on-site periodically. The Coder 3 is responsible for performing job duties in accordance with the mission, vision and values of Tampa General Hospital.

Essential Functions:

• Reviewing medical records and assigning diagnostic and procedural codes using ICD-9-CM/ICD-10 CM/PCS and CPT/HCPCS and any other designated coding classification system in accordance with coding guidelines.

• Assigning and sequencing codes accurately based on medical record documentation

• Assigning the appropriate discharge disposition.

• Abstracting and entering coded data for hospital statistical and reporting requirements

• Communicating documentation improvement opportunities and coding issues to appropriate personnel for follow up and resolution.

• Adhering to accuracy and productivity levels established by the department.

• Communicating with co-workers, management, and hospital staff regarding clinical and reimbursement issues.

• Adhering to the American Health Information Management Association's code of ethics and departmental Code of Integrity.

• Maintain coding credential along with any required CEUs for ongoing credential maintenance and subject matter expertise.

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).

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

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

• Advanced knowledge of computerized encoding and abstracting software.

• Excellent professional verbal and written communication skills.

• At least five 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.

Preferred:

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

• Experience with Epic electronic medical record software and 3M encoding and abstracting software.

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