Clinical Coding Specialist III - Per Diem Variable

Cape Fear Valley Health; Fayetteville (NC); On-site; USD 60,000 - 80,000; Part time

Job summary

A leading health facility is seeking a Clinical Documentation Specialist to ensure accurate coding and documentation of medical records. Ideal candidates will have over 5 years of coding experience in a healthcare environment, a Bachelor's Degree in Health Information Management, and relevant certifications. The role requires thorough knowledge of medical terminology and coding principles while maintaining high standards of accuracy under pressure.

Qualifications

• 5+ years coding experience, preferably in a hospital setting.
• Knowledge of ICD-CM coding principles under Prospective Payment System.
• Familiarity with medical record content and UHDDS definitions.

Responsibilities

• Reviews the entire medical record to code conditions accurately.
• Maintains an accurate case mix index for administrative decisions.
• Assigns accurate codes using good judgment in a timely manner.

Skills

Medical terminology

Anatomy and physiology

Excellent communication skills

Education

Bachelor's Degree in Health Information Management

RHIA, RHIT, CCS

Job description

3 days ago Be among the first 25 applicants

Summary

Reviews thoroughly the entire medical record to code specifically and accurately those conditions or diagnoses that were treated or affected the patient's plan of care. Verifies that each medical record contains appropriate documentation to justify the selected principal diagnosis to identify comorbid conditions, complications and procedures to use for DRG Assignment. Maintains an accurate case mix index from which administration makes critical management and strategic planning decisions.5+ years coding experience required, preferably in a hospital setting. Two years inpatient coding preferred. Experience in a Health Information Management in an acute care facility, or with a Peer Review Organization, in Quality Assurance, or Utilization Review preferred. Bachelor's Degree in Health Information Management or equivalent training and experience. RHIA, RHIT, CCS or other equivalent credentials required. 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 required. Highly independent in 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. Utilizes past experience, practices and organization to accomplish goals. Assigns accurate codes using good judgment in a timely manner within broad guidelines. Must be flexible and able to concentrate in a busy, noisy, and crowded environment with demands and interruptions 75% of the time.Near visual acuity required. Motor coordination required to operate computer. Work requires commuting between nursing units and Medical Record Department.

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Health Information Management

Job Family

Clerical

Work Shift

Variable (United States of America)

Summary

Reviews thoroughly the entire medical record to code specifically and accurately those conditions or diagnoses that were treated or affected the patient's plan of care. Verifies that each medical record contains appropriate documentation to justify the selected principal diagnosis to identify comorbid conditions, complications and procedures to use for DRG Assignment. Maintains an accurate case mix index from which administration makes critical management and strategic planning decisions.5+ years coding experience required, preferably in a hospital setting. Two years inpatient coding preferred. Experience in a Health Information Management in an acute care facility, or with a Peer Review Organization, in Quality Assurance, or Utilization Review preferred. Bachelor's Degree in Health Information Management or equivalent training and experience. RHIA, RHIT, CCS or other equivalent credentials required. 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 required. Highly independent in 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. Utilizes past experience, practices and organization to accomplish goals. Assigns accurate codes using good judgment in a timely manner within broad guidelines. Must be flexible and able to concentrate in a busy, noisy, and crowded environment with demands and interruptions 75% of the time.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 System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity

Seniority level

• Seniority level

  Mid-Senior level

Employment type

• Employment type

  Part-time

Job function

• Job function

  Health Care Provider

• Industries

  Hospitals and Health Care

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