Clinical Coding Specialist III- Per Diem Days

Cape-Fear-Valley-Medical-Center-; Fayetteville (NC); On-site; USD 70,000 - 95,000; Full time

Job summary

Cape Fear Valley Medical Center in Fayetteville, NC seeks a Health Information Management professional to code diagnoses, procedures, and treatments for hospital encounters. You will abstract admissions for reimbursement and ensure documentation supports principal diagnoses and comorbidities.

The role requires hospital coding experience with RHIA/RHIT/CCS credentials and strong communication with physicians to optimize DRG outcomes.

Qualifications

• Bachelor's degree in Health Information Management or 8 years of equivalent training and experience.
• RHIA, RHIT, CCS or other equivalent credentials are required.
• Minimum 5 years coding experience in a hospital setting; 2 years inpatient coding preferred.
• In-depth knowledge of UHDDS, ICD-CM coding principles, and payer rules.

Responsibilities

• Code diagnoses, treatments, and procedures using appropriate coding systems.
• Abstract hospital admissions for reimbursement and statistical reporting.
• Code LTAC, Rehab and acute care inpatients per payer requirements with encoder/DRG grouper.
• Explain principal diagnosis changes to physicians when documentation affects attestation.
• Assess documentation adequacy to support principal diagnoses, procedures, and comorbidities.
• Collaborate with Clinical Documentation Specialists and Reimbursement Specialists to improve physician documentation.
• Analyze clinical findings to determine secondary diagnoses for severity indices and appropriate DRG.
• Delay billing when additional documentation is needed for optimal DRG assignment.

Skills

UHDDS knowledge

ICD-CM coding

Physician communication

Medical terminology

Analytical reasoning

Education

Bachelor's degree in Health Information Management

RHIA/RHIT/CCS or equivalent credentials

5 years hospital coding experience

2 years inpatient coding preferred

1 year HIM experience in acute care

Tools

Encoder software

DRG grouper

Job description

FacilityCape Fear Valley Medical CenterLocationFayetteville, North CarolinaDepartmentHealth Information ManagementJob FamilyClericalWork ShiftVariable (United States of America)SummaryThoroughly review the entire medical record to code specifically and accurately those conditions or diagnoses that were treated or affected the patient's plan of care. Verify medical records contain appropriate documentation to justify the selected principal diagnosis to identify comorbid conditions, complications and procedures to use for DRG Assignment. Maintain accurate case mix index from which administration makes critical management and strategic planning decisions.Major Job FunctionsThe following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:Code diagnoses, treatments, and procedures according to the appropriate classification system for that category of patient encounter and in accordance with provisions of the Uniform Hospital Discharge Data Set as well as the interpretation of these provisions as issued by the American Hospital Association and American Health Information Management Association and all governmental and private Third Party rules and regulationsPerform medical record abstracting of hospital admissions for reimbursement and statistical reportingConcurrently code LTAC, Rehab and acute care inpatients based on prescribed requirements by payer, using a computerized encoder and DRG grouperExplain to and communicate with physicians regarding the changing of principal diagnoses on the attestation statement, based on lab and other diagnostic findings, when the record may be subjected to PRO review due to vague attestation/documentationAssess the adequacy of documentation to ensure it supports the principal diagnosis, principal procedure and complications and comorbid conditions that are codedWorks with Clinical Documentation Specialists and Reimbursement Specialists to identify areas for improvement in physician documentationAssess OCE, NCCI and CCI edits as necessary to apply appropriate modifiers and make appropriate referrals to revenue departments, claim billers, senior coders and other hospital contacts as needed for accurate claim submissionAnalyze clinical findings to determine appropriate secondary diagnoses for patient severity indicesUse good judgment in determining when to delay billing for obtaining additional documentation to support the assignment of a more optimal DRGMake coding supervisor aware of problem issues, negative physician communication and/or other influences that impact effectiveness of job performanceOther duties as assignedMinimum QualificationsThe following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:Education and Formal Training:Bachelor's degree in Health Information Management required OR 8 years of equivalent training and experience requiredRHIA, RHIT, CCS or other equivalent credentials requiredWork Experience:5 years coding experience required, preferably in a hospital setting2 years inpatient coding preferred1 year Health Information Management experience in an acute care facility, Peer Review Organization, Quality Assurance, or Utilization Review preferredKnowledge, Skills, and Abilities Required:Proficiency in reading, writing, and speaking the English languageMedical terminology, anatomy and physiology, familiarity with medical record content and an understanding of the Uniform Hospital Discharge Data Set (UHDDS) definitionsKnowledge of ICD-CM coding principles under Prospective Payment SystemExcellent communication skillsUnderstanding that decisions are made with very serious impact affecting hospital reimbursement and PRO review determinationsHigh degree of interpretation, analysis, planning, coordination, and organization of informationDecisions require intense mental effort and consideration of reimbursement ramificationsAbility to utilize experience, practices and organization to accomplish goalsAbility to assign accurate codes using good judgment in a timely manner within broad guidelinesFlexible and able to concentrate in a busy, noisy, and crowded environment with demands and interruptions 75% of the timePhysical Requirements:Near visual acuity requiredMotor coordination required to operate computerWork requires commuting between nursing units and Medical Record DepartmentRequired Licenses and CertificationsRHIA - American Health Information Management AssociationCape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity