Inpatient Coder III / HIM Coding

William Backus Hospital Hartford , CT 06183

Posted 3 months ago

Work where every moment matters.

Every day, almost 25,000 Hartford HealthCare employees come to work with one thing in common: Pride in what we do, knowing every moment matters here. We invite you to become part of Connecticut's most comprehensive healthcare network.

The creation of the HHC System Support Office recognizes the work of a large and growing group of employees whose responsibilities are continually evolving so that we and our departments now work on behalf of the system as a whole, rather than a single member organization.

With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system.

Position Summary

Review complex inpatient clinical documentation to determine the appropriate assignment of alpha numeric diagnosis/procedure codes and Medicare Severity Diagnosis Related Groups (MS-DRG). Data is classified for internal and external statistical reporting, research, regulatory compliance and reimbursement.

Mentors other coders in understanding policies and procedures and HIM systems; supports and participates in special projects and assignments; and provides subject matter expert guidance to others and recommends corrective actions to Manager.

Role Responsibilities

Coding

  • Applies knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to determine the appropriate assignment of diagnosis and procedure codes.

  • Analyzes medical records using the Uniform Hospital Discharge Data Set (UHDDS), interprets documentation and assigns proper International Classification of Diseases, Ninth Edition, Clinical Modification (ICD9CM)/ International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnoses and ICD-9-CM and ICD-10-PCS (Procedural Classification System) operative procedure codes utilizing designated software to included Computer Assisted Coding (CAC) and/or encoder, coding manuals and other reference material.

  • Adheres to all department coding procedures, policies, guidelines and quality standards.

  • Reviews DRG assigned to each record. Enters coded/abstracted information into software, analyzes DRG groupings, and observes for appropriate DRG assignment.

Finance

  • Collaborate with clinical documentation specialists (CDS) to determine appropriate MS-DRG assignment for compliance and reimbursement purposes.

  • Complete on a daily basis cases that have been assigned to them utilizing the appropriate work lists.

Communication

  • Seeks clarification from physicians in cases where documentation is absent, ambiguous, or contradictory.

Training

  • If required, assists in training and mentoring new coders to become acclimated to new environment, and understanding internal coding policies and procedures.

Other

  • Mentors other coders during their orientation period and assists them in understanding policies and procedures and HIM systems.

  • Supports and participates in special projects and assignments.

  • Provides subject matter expert guidance to others and recommends corrective actions to the Manager.

  • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.

  • Assist manager with other tasks as necessary

  • Backs up manager in his/her absence

  • Acts as Lead for coding teams as assigned

  • Meet revenue cycle goals (Key Performance Indicators (KPI), Productivity Standards)

Education/Experience Required

  • High school diploma or General Education Development (GED) required.

  • Associate Degree preferred.

Four or more years of progressive on-the-job coding experience in an acute care hospital setting.

License/Certification Required

Certified Coding Specialist (CCS) certification required and maintained thereafter

Knowledge, Skills and Abilities:

KNOWLEDGE OF:

  • ICD9CM/ICD-10-CM diagnosis and ICD-9-CM/ICD-10-PCS operative procedure codes

  • Uniform Hospital Discharge Data Set (UHDDS)

  • MS-DRG

  • Working knowledge of clinical information

  • Microsoft Office Products; Word, Excel

Encoder and/or CAC

SKILLS:

  • Read, write and speak English proficiently.

  • Solid analytical capabilities.

  • Good organizational skills.

Proficiently read and interpret physician writing.

ABILITY TO:

  • Function independently.

  • Handle multiple priorities.

  • Listen and acknowledge ideas and expressions of others attentively.

  • Converse clearly using appropriate verbal and body language.

  • Collaborate with others to achieve a common goal through mutual cooperation.

  • Influence others for positive and productive outcomes.

  • Utilize coding subject matter expertise to support Level 1 and Level 2 coders and others in the organization as needed.

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With the creation of our new umbrella organization we now have our own identity with a unique payroll, benefits, performance management system, service recognition programs and other common practices across the system. Position Summary Review complex inpatient clinical documentation to determine the appropriate assignment of alpha numeric diagnosis/procedure codes and Medicare Severity Diagnosis Related Groups (MS-DRG). Data is classified for internal and external statistical reporting, research, regulatory compliance and reimbursement. Mentors other coders in understanding policies and procedures and HIM systems; supports and participates in special projects and assignments; and provides subject matter expert guidance to others and recommends corrective actions to Manager. Role Responsibilities Coding * Applies knowledge of anatomy and physiology, clinical disease processes, pharmacology, and diagnostic and procedural terminology to determine the appropriate assignment of diagnosis and procedure codes. * Analyzes medical records using the Uniform Hospital Discharge Data Set (UHDDS), interprets documentation and assigns proper International Classification of Diseases, Ninth Edition, Clinical Modification (ICD‑9‑CM)/ International Classification of Diseases, Tenth Edition, Clinical Modification (ICD-10-CM) diagnoses and ICD-9-CM and ICD-10-PCS (Procedural Classification System) operative procedure codes utilizing designated software to included Computer Assisted Coding (CAC) and/or encoder, coding manuals and other reference material. * Adheres to all department coding procedures, policies, guidelines and quality standards. * Reviews DRG assigned to each record. Enters coded/abstracted information into software, analyzes DRG groupings, and observes for appropriate DRG assignment. Finance * Collaborate with clinical documentation specialists (CDS) to determine appropriate MS-DRG assignment for compliance and reimbursement purposes. * Complete on a daily basis cases that have been assigned to them utilizing the appropriate work lists. Communication * Seeks clarification from physicians in cases where documentation is absent, ambiguous, or contradictory. Training * If required, assists in training and mentoring new coders to become acclimated to new environment, and understanding internal coding policies and procedures. Other * Mentors other coders during their orientation period and assists them in understanding policies and procedures and HIM systems. * Supports and participates in special projects and assignments. * Provides subject matter expert guidance to others and recommends corrective actions to the Manager. * Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. * Assist manager with other tasks as necessary * Backs up manager in his/her absence * Acts as Lead for coding teams as assigned * Meet revenue cycle goals (Key Performance Indicators (KPI), Productivity Standards) Qualifications Education/Experience Required * High school diploma or General Education Development (GED) required. * Associate Degree preferred. Four or more years of progressive on-the-job coding experience in an acute care hospital setting. License/Certification Required Certified Coding Specialist (CCS) certification required and maintained thereafter Knowledge, Skills and Abilities: KNOWLEDGE OF: * ICD‑9‑CM/ICD-10-CM diagnosis and ICD-9-CM/ICD-10-PCS operative procedure codes * Uniform Hospital Discharge Data Set (UHDDS) * MS-DRG * Working knowledge of clinical information * Microsoft Office Products; Word, Excel Encoder and/or CAC SKILLS: * Read, write and speak English proficiently. * Solid analytical capabilities. * Good organizational skills. Proficiently read and interpret physician writing. ABILITY TO: * Function independently. * Handle multiple priorities. * Listen and acknowledge ideas and expressions of others attentively. * Converse clearly using appropriate verbal and body language. * Collaborate with others to achieve a common goal through mutual cooperation. * Influence others for positive and productive outcomes. * Utilize coding subject matter expertise to support Level 1 and Level 2 coders and others in the organization as needed. Hartford Healthcare Hartford CT

Inpatient Coder III / HIM Coding

William Backus Hospital