Clinical Documentation Coding Specialist II

University of Utah Health; Salt Lake City (UT); On-site; USD 85,000 - 110,000; Full time

Job summary

University of Utah Health in Salt Lake City seeks an inpatient facility coder with CDI support responsibilities. You will assign ICD-10-CM/PCS codes, POA indicators, and MS-DRG/APR-DRG sequences while abstracting admission data and ensuring compliance with CMS guidelines.

The role requires 3+ years of inpatient coding experience and AHIMA credentials, with proficiency in Epic and 3M Encompass. This is a full-time position in a hospital setting.

Qualifications

• This role requires inpatient facility coding experience and AHIMA/CCS/RHIA/RHIT certification.
• Proficiency in medical terminology, anatomy, physiology, and coding guidelines.
• Ability to discuss and justify complex coding decisions with clinical staff.

Responsibilities

• Reviews medical records to identify diagnoses and procedures.
• Assigns principal and secondary ICD-10-CM/PCS codes and POA indicators.
• Sequences codes for MS-DRG/APR-DRG assignments.
• Abstracts data elements like admit type, origin, and discharge disposition.
• Adheres to official coding guidelines and query practices.

Skills

Medical terminology

ICD-10 coding

CMS guidelines

Communication skills

Team collaboration

Microsoft Office

Epic knowledge

3M 360 Encompass

Education

RHIA/RHIT/CCS certification

Bachelor’s or Associate degree in related field

Tools

Epic

3M 360 Encompass R2

Job description

Overview

As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission. EO/AA

This position provides inpatient facility coding and Clinical Documentation Improvement (CDI) support in the Health Information Management department with minimal educational intervention required.

Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

Responsibilities

Essential Functions

• Performs thorough review of medical record for identification of relevant clinical diagnoses and procedures performed.
• Assigns appropriate ICD-CM principal diagnosis code.
• Assigns appropriate ICD-CM secondary diagnosis codes.
• Assigns appropriate ICD-10 PCS code(s).
• Sequences principal and secondary diagnoses codes and primary procedure code for accurate MS-DRG and APR-DRG assignment.
• Assigns Present on Admission (POA) indicator for each diagnosis code.
• Abstracts required data elements, including but not limited to: Admit Type, Admit Source / Point of Origin, and Discharge Disposition.
• Expands understanding / identification of opportunities where additional provider documentation is required to thoroughly and accurately assign ICD-10 code.
• Understands and adheres to compliant provider query practices and procedures.
• Understands and adheres to Health Information Coding policies and Official Coding Guidelines, as published by CMS and Cooperating Parties.

Knowledge / Skills / Abilities

• Proficient knowledge of medical terminology, anatomy & physiology and pathophysiology.
• Knowledge of basic coding conventions & use of coding nomenclature.
• Developing knowledge of health care quality related initiatives.
• Demonstration of acceptable progression through service lines of increasing complexity.
• Achieve and sustain acceptable productivity rate as defined by Coding Leadership.
• Ability to effectively communicate with clinical staff and other hospital department personnel.
• Knowledge of healthcare IT systems, preferably Epic and 3M 360 Encompass R2.
• Knowledge of Microsoft Office.
• Team player, ability to collaborate with colleagues and leadership.

Qualifications

Required

• Minimum of three (3) years of experience coding inpatient facility (HB).

Licenses Required

• One of the following
• Current RHIA Certification with the American Health Information Management Association (AHIMA).
• Current RHIT Certification with the American Health Information Management Association (AHIMA).
• Current CCS Certification with the American Health Information Management Association (AHIMA).

* Additional license requirements as determined by the hiring department.

Qualifications (Preferred)

Preferred

• Bachelor's or Associate's degree in a related field.

Working Conditions and Physical Demands

Employee must be able to meet the following requirements with or without an accommodation.

• This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions.

Physical Requirements

Listening, Sitting, Speaking

Multi-lingual Candidates Welcomed

EEO Statement

University of Utah Health Hospitals and Clinics, a part of The University of Utah, values candidates who have experience working in settings with students and patients from all backgrounds and possess a strong commitment to improving access to higher education and quality healthcare for historically underrepresented students and patient populations.

All qualified individuals are encouraged to apply. Veterans’ preference is extended to qualified applicants, upon request and consistent with University policy and Utah state law. Upon request, reasonable accommodations in the application process will be provided to individuals with disabilities.

University of Utah Health Hospitals and Clinics, a part of The University of Utah, is an *Affirmative Action/Equal Opportunity employer and does not discriminate based upon race, ethnicity, color, religion, national origin, age, disability, sex, sexual orientation, gender, gender identity, gender expression, pregnancy, pregnancy-related conditions, genetic information, or protected veteran's status. The University does not discriminate on the basis of sex in the education program or activity that it operates, as required by Title IX and 34 CFR part 106. The requirement not to discriminate in education programs or activities extends to admission and employment. Inquiries about the application of Title IX and its regulations may be referred to the Title IX Coordinator, to the Department of Education, Office for Civil Rights, or both.

To request a reasonable accommodation for a disability, please contact the University of Utah Health Hospitals and Clinics Human Resources office at 801-581-6500. If you or someone you know has experienced discrimination or sexual misconduct including sexual harassment, you may contact the Director/Title IX Coordinator in the Office of Equal Opportunity (OEO). More information, including the Director/Title IX Coordinator's office address, electronic mail address, and telephone number can be located at: www.utah.edu/nondiscrimination/
Online reports may be submitted at oeo.utah.edu/

The University is a participating employer with Utah Retirement Systems (“URS”). Eligible new hires with prior URS service, may elect to enroll in URS if they make the election before they become eligible for retirement (usually the first day of work). Contact Hospitals and Clinics Human Resources at [phone] for information. Individuals who previously retired and are receiving monthly retirement benefits from URS are subject to URS’ post-retirement rules and restrictions. Please contact Utah Retirement Systems at [phone] or [phone] or Hospitals and Clinics Human Resources at [phone] if you have questions regarding the post-retirement rules.

This position may require the successful completion of a criminal background check and/or drug screen.

Requisition Number 85988
Reg/Temp Regular
Employment Type Full-Time
Shift Day
Work Schedule Monday-Friday 8am-4:30pm
Clinical/Non-Clinical Status Non-Clinical
Location Name Business Services Building
Workplace Set Up Remote
City SALT LAKE CITY
State UT
Department COR CST 17A HEALTH INFO CODING
Category Health Information Management
Workplace Set Up Remote