Coder III

Job Description Summary

Under general supervision of HB coding manager and according to established procedures, assigns diagnostic codes as well as EM leveling for facility to medical record information. The Facility Coder III is an advanced outpatient coder role responsible for accurate and timely assignment of diagnosis, CPT/HCPC and Evaluation and Management codes for all Facility Observation cases Using established department policies and procedures in conjunction with the current version of ICD-CM Classification for Hospitals, the Facility Coder III will assign the most appropriate codes for OPPS. Facility Coder III will utilize their experience and knowledge to determine the correct first list diagnosis, secondary diagnoses, CPT procedure codes and secondary procedure codes. The Coder III is empowered at South Shore Hospital to query providers when documentation requires clarification and he/she proactively works with HIM and medical leadership to address concerning documentation trends. The Coder III works with direct support from and under the direction of the HIM Coding Manager to make certain their skills and knowledge remain in peak condition. As a vital member of our respected team, the Coder III will work collaboratively with other areas of the Health Information Management department and the Clinical Documentation Integrity unit to advance the profession and reinforce the valuable contributions coders make to the care delivery system.

Job Description

ESSENTIAL FUNCTIONS:

1 - Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures. Assigns proper ICD-CM and CPT diagnostic and operative procedure codes to charts and related records by reference to designated coding manuals and other reference material.

a - Codes to accepted industry and South Shore production standards consistently with 95% accuracy.

b - Maintains within three (3) days after discharge coding requirements.

2 - Applies Uniform Hospital Discharge Data Set definitions to select the first listed diagnosis, first listed procedure and all other diagnoses and procedures which require coding, as well as other data items required to maintain the Hospital database.

a - Verifies that coded information is entered into the databases without any errors within three (3) days of patient discharge.

3 - Applies sequencing guidelines to coded data according to official coding rules.

4 - Assesses the adequacy of medical record documentation to ensure that it supports medical necessity and the assigned codes. Consults with the appropriate physician and/or appropriate parties to clarify medical record information.

a - Identifies any documentation inadequacies with physician and/or appropriate parties and clarifies medical record information with courtesy and tact.

5 - Answers physicians/clinician questions regarding coding principles, and Prospective Payment System. Assists Finance, Data Processing and other departments with coding issues.

a - Assists physicians and ancillary departments with coding questions with timeliness, courtesy and tact.

6 - Remains abreast of developments in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature and so forth.

a - Utilizes professional affiliations, etc., in order to maintain current in professional developments.

b - Attends all pertinent coding seminars.

c - Completes in required time frame all coding clinic quizzes sent by Coding Manager

7. Aggressively protects patients' health information and maintains strict adherence to hospital and regulatory rules regarding privacy and confidentiality of such information

Technology and Learning

a - Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization.

b - Embraces technological advances that allow us to communicate information effectively and efficiently based on role.

JOB REQUIREMENTS

Minimum Education - Preferred

JOB REQUIREMENTS

Minimum Education – Preferred

Associates Degree in Health Information Management or compensatory work experience

Minimum Work Experience

Six to twelve (6–12) months of experience in an acute facility setting preferred.

Required Certifications

CCS – Certified Coding Specialist or CPC – Certified Professional Coder or COC - Certified Outpatient Coder

Required additional Knowledge and Abilities

Eligible for designation as a RHIT, RHIA preferred.

Experience with EPIC and/or Solventum 360 preferred