Clinical Coding Specialist III- Per Diem Days

Cape Fear Valley Health; Fayetteville, Northern (NC, KY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Cape Fear Valley Health in Fayetteville, NC, seeks a Health Information Management professional to code diagnoses, procedures and charges for hospital encounters. You will ensure UHDDS compliance and accurate DRG assignment.

Responsibilities include medical record abstraction, physician attestation communication, and collaboration with reimbursement teams to improve documentation and claim accuracy.

Qualifications

• Bachelor's degree in Health Information Management or equivalent 8 years experience.
• 5 years coding experience; 2 years inpatient preferred.
• RHIA/RHIT/CCS or equivalent credentials required.
• Proficiency in reading, writing, and speaking English.
• Knowledge of UHDDS definitions and ICD-CM coding principles.
• Excellent communication skills.
• Ability to work in a busy hospital env with focus on accuracy.

Responsibilities

• Code diagnoses, treatments and procedures per UHDDS guidelines and payer rules.
• Perform medical record abstracting for reimbursement and statistics.
• Concurrently code LTAC, Rehab and acute care inpatients per payer requirements.
• Explain principal diagnoses changes to physicians for attestation statements.
• Assess documentation to support principal diagnosis, procedures and comorbidities.
• Collaborate with CDI and Reimbursement Specialists to improve documentation.
• Assess OCE, NCCI and CCI edits to apply modifiers and refer for billing.
• Analyze findings to determine secondary diagnoses for severity indices.
• Know when to delay billing for additional documentation.
• Notify coding supervisor of issues affecting performance.
• Other duties as assigned.

Skills

English proficiency

Communication skills

ICD-CM coding

UHDDS knowledge

Education

Bachelor's degree in Health Information Management

RHIA/RHIT/CCS credentials

Tools

Computer encoder

DRG grouper

Job description

Facility Cape Fear Valley Medical Center

Location Fayetteville, North Carolina

Department Health Information Management

Job Family Clerical

Work Shift Variable (United States of America)

Thoroughly 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 Functions

• 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 regulations
• Perform medical record abstracting of hospital admissions for reimbursement and statistical reporting
• Concurrently code LTAC, Rehab and acute care inpatients based on prescribed requirements by payer, using a computerized encoder and DRG grouper
• Explain 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/documentation
• Assess the adequacy of documentation to ensure it supports the principal diagnosis, principal procedure and complications and comorbid conditions that are coded
• Works with Clinical Documentation Specialists and Reimbursement Specialists to identify areas for improvement in physician documentation
• Assess 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 submission
• Analyze clinical findings to determine appropriate secondary diagnoses for patient severity indices
• Use good judgment in determining when to delay billing for obtaining additional documentation to support the assignment of a more optimal DRG
• Make coding supervisor aware of problem issues, negative physician communication and/or other influences that impact effectiveness of job performance
• Other duties as assigned

Minimum Qualifications

• Education and Formal Training: Bachelor's degree in Health Information Management required OR 8 years of equivalent training and experience required RHIA, RHIT, CCS or other equivalent credentials required
• Work Experience: 5 years coding experience required, preferably in a hospital setting 2 years inpatient coding preferred 1 year Health Information Management experience in an acute care facility, Peer Review Organization, Quality Assurance, or Utilization Review preferred
• Knowledge, Skills, and Abilities Required: Proficiency in reading, writing, and speaking the English language
• Medical terminology, anatomy and physiology, familiarity with medical record content and an understanding of the Uniform Hospital Discharge Data Set (UHDDS) definitions
• Knowledge of ICD-CM coding principles under Prospective Payment System
• Excellent communication skills
• Understanding that decisions are made with very serious impact affecting hospital reimbursement and PRO review determinations
• High degree of interpretation, analysis, planning, coordination, and organization of information
• Decisions require intense mental effort and consideration of reimbursement ramifications
• Ability to utilize experience, practices and organization to accomplish goals
• Ability to assign accurate codes using good judgment in a timely manner within broad guidelines
• Flexible and able to concentrate in a busy, noisy, and crowded environment with demands and interruptions 75% of the time

Physical Requirements

Near visual acuity required Motor coordination required to operate computer Work requires commuting between nursing units and Medical Record Department

Required Licenses and Certifications

RHIA - American Health Information Management Association

Cape Fear Valley Health is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity

For exceptional healthcare come to Cape Fear Valley Health where caring employees are committed to integrity, patient-centeredness and excellence throughout the entire healthcare process. At Cape Fear Valley Health, our goal is to improve the quality of every life we touch. Our diverse team of doctors, nurses and staff work together to create a better experience for every patient, every time. Cape Fear Valley is a 950-bed, 8-hospital regional health system, the 8th largest in North Carolina, with more than 1 million inpatient and outpatients annually. A private not-for-profit organization with over 7,000 employees and 850 physicians. Our employees and physicians proudly serve a seven-county region of southeastern North Carolina, including Fayetteville, Fort Bragg, Hope Mills, Raeford, Lumberton, Elizabethtown, Clinton, Lillington, Dunn and beyond. Our medical facilities include Cape Fear Valley Medical Center, Highsmith-Rainey Specialty Hospital, Cape Fear Valley Rehabilitation Center, Behavioral Health Care, Bladen County Hospital, Hoke Hospital, Central Harnett Hospital, Betsy Johnson Hospital, as well as more than 60 medical offices and specialty care clinics spread throughout the Cape Fear region.