Atrium Health Job - 44368953 | CareerArc
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Company: Atrium Health
Location: Winston-Salem, NC
Career Level: Entry Level
Industries: Healthcare, Pharmaceutical, Biotech

Description

Overview

Coder I Facility HB, Outpatient Coding

40 hours per week, day shift

JOB SUMMARY:

This apprentice-level position is responsible for the coding of medical information into the WakeOne medical records abstracting system and for monitoring completion of the coding function through established best practice processes, and professional and regulatory coding guidelines. The position is responsible for assigning ICD and CPT and/or PCS codes and reviewing/editing associated facility charges as directed for the ambulatory encounters as assigned.  Data reported by this incumbent is used to meet licensure requirements, is used for statistical purposes, and for financial and billing purposes.  Incumbent(s) operate under the general supervision of the Manager Facility Coding, Health Information Management.

EDUCATION/EXPERIENCE:

  1. Minimum of two years of coding experience or coding certification CCA, CIC, CPC-A, CPC-H, CPC, CCS, RHIT, or RHIA preferred.
  2. Coding certification is required within 12 months of employment.
  3. Knowledge of medical coding normally acquired through 6 months experience in a hospital coding department preferred.
  4. Satisfactory completion of college level courses in anatomy and physiology and medical terminology.

REPORTS TO:  Manager Facility Coding

LICENSURE, CERTIFICATION, and/or REGISTRATION:

  • Minimum of two years of coding experience or coding certification CCA, CIC, CPC-A, CPC-H, CPC, CCS, RHIT, or RHIA preferred.

ESSENTIAL FUNCTIONS: 

Ensures the timely and accurate coding and completion of patient accounts within established departmental accuracy and productivity standards.

  1. Accurately completes required data fields for account completion, including but not limited to discharge disposition, admit source, admitting provider, attending provider, surgical provider, referring provider, procedure dates, procedure locations, etc.
  1.  Applies correct ICD CM and CPT guidelines meeting departmental policy regarding compliant methods, timeframes, use of applications and productivity.
  2. Assists in demonstrating medical necessity for procedures performed by ensuring that all documented disease processes are coded.
  3. Demonstrates proficiency in utilizing official coding books as well as the electronic medical record, computer assisted coding/encoding software, and clinical documentation information systems to facilitate code assignment.
  4. Reviews facility charges as provided and edits where necessary to ensure charges are compliant and substantiated by provider documentation.
  5. Demonstrates full understanding and is compliant with correct coding initiative guidelines, regulatory requirements regarding coding of medical information including but not limited to external regulatory agencies such as Quality Improvement Organizations (QIOs), the Centers for Medicare & Medicaid Services (CMS) and other payers, and the Joint Commission.
  6. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
  7. Queries physician when existing documentation is unclear or ambiguous following AHIMA guidelines and established policy. 
      1. Follow guidelines for writing compliant queries.
      2. Compose queries using correct grammar and spelling.
      3. Write concise queries, considering the provider's viewpoint when composing the query.
      4. Ensures all open queries initiated by the Clinical Documentation Consultants have been addressed prior to final coding. 
  1. Brings identified concerns to Manager Coding for resolution.
  2. Assigns the MS DRG and MCC/CCs that most appropriately reflect documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with depart
  3. Performs administrative duties in support of the overall coding function as assigned.
  4.  Reviews department-specified reports daily to identify charts that need to be coded based and prioritizes as per department-specific guidelines and within designated timelines. 
  5. Follows up to ensure that any edits that prevent an account from dropping are corrected within established timelines.
  6. Produces specific reports on a monthly basis per established parameters.
  7. Responds to inquiries from Patient Accounts or other departments as requested.  Communicates with Manager when trending request volumes impact productivity.
  8. Demonstrates continuous learning as evidenced by personally developed reference materials, online publications etc., to stay abreast of new and revised guidelines, practices and terminology, for reference and application.
  9. Participates in on site and/or external training workshops as opportunities arise.
  10. Maintains credentials, if applicable, and submits written evidence of maintenance.
  11. Participates as a member of the Clinical Documentation Management Program.
  1. Mentors and assists in the training and professional growth of other team members
  2. Consults with the Clinical Documentation Specialists and Coding Compliance Coordinators as needed.
  3. Consults with and educates/trains providers and other staff on coding practices and conventions.
  4. Attends and participates in continuing education including in-service programs, coding seminars and workshops to maintain current understanding of coding developments, changes, and regulations.
  5. Understands how ICD codes, DRGs and SOI/ROM scores are used for reimbursement, public reporting of outcomes, reviewing quality of patient care, reporting organizational performance to regulatory agencies and benchmarking organizations, financial modeling, strategic planning and marketing.
  6. Assists Managers as requested. 

SKILLS & QUALIFICATIONS:

  1. Ability to concentrate for extended periods of time.
  2. Knowledge of medical terminology and basic anatomy and physiology.
  3. Must possess strong customer service skills.
  4. Ability to work effectively, independently, and manage multiple demands consistently.
  5. Ability to apply broad guidelines to specific coding situations; independently utilizing discretion and a significant level of analytic ability.
  6. Effective verbal and written communication and customer service skills.
  7. Ability to operate multiple Windows based software applications.
  8. Ability to solve problems with close attention to detail.
  9. Ability to work and make decisions independently.

WORK ENVIRONMENT:

  • Moderate noise environment.
  • Clean, well lit area.
  • Comfortable climate.
 PHYSICAL REQUIREMENTS:

Amount of time spent performing the following activities:

0%

35%

65%

 

 

to

to

to

 

 

35%

65%

100%

N/A

Activity

X

 

 

 

Standing

X

 

 

 

Walking

 

 

X

 

Sitting

X

 

 

 

Bending

X

 

 

 

Reaching with arms

 

 

X

 

Finger and hand dexterity

 

X

 

 

Talking

 

X

 

 

Hearing

 

 

X

 

Seeing

X

 

 

 

Lifting, carrying, pushing and or pulling:

X

 

 

 

20 lbs. maximum

 

 

 

X

50 lbs. maximum

 

 

 

X

100 lbs. maximum

 


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