Health Information Management Inpatient Coder, FT, Days, Remote

Prisma Health; Greenville (SC); Remote; USD 50,000 - 80,000; Full time

Job summary

Join a transformative healthcare organization that inspires health and serves with compassion. In this vital role, you'll code medical information into billing systems, ensuring accuracy and compliance with established guidelines. Your expertise in ICD and inpatient coding will help capture critical data for major traumas and NICU records. Collaborate with clinical documentation specialists and participate in ongoing training to enhance your skills. This position offers a unique opportunity to make a difference in the healthcare landscape while working in a supportive environment dedicated to excellence and innovation.

Benefits

Health Insurance

Retirement Plan

Paid Time Off

Professional Development Opportunities

Qualifications

• Certification in coding and 3 years of inpatient coding experience required.
• Strong knowledge of medical terminology and anatomy essential.

Responsibilities

• Apply ICD and ICD-PCS codes to inpatient records accurately.
• Review work queues and prioritize coding tasks daily.

Skills

ICD Coding

Medical Terminology

Electronic Medical Records

3M or Encoder System

Clinical Documentation Improvement

MS DRG Payment System

EPIC System

Attention to Detail

Independent Decision Making

Education

Associate Degree or Coding Certificate

Certification from AHIMA

IP Coder Associate Program Completion

Tools

Computer-Assisted Coding Software

Clinical Documentation Information Systems

Job description

Inspire health. Serve with compassion. Be the difference.

Job Summary

Codes medical information into the organization billing/abstracting systems and completes the coding function through established best practice processes and professional and regulatory coding guidelines. Performs Inpatient coding including major traumas and Neonatal Intensive Care Unit (NICU) records by assigning International Classification of Diseases (ICD) and International Classification of Diseases-Procedure Coding System (ICD-PCS) codes as well as the Diagnosis Related Groups (DRG) assignment. Abstracts, assigns, and verifies codes for Major Complications and Comorbidities/Complications and Comorbidities (MCC/CCs), Hospital-Acquired Condition/Patient Safety Indicator (HAC/PSI), and Quality Indicators capture as appropriate through documentation validation. Ensures that each diagnosis present on admission (POA) indicator is assigned appropriately. Codes for multiple facilities. Adheres to Prisma Health Coding and Compliance policies and procedures for assignment of complete, accurate, timely, and consistent codes. Data reported by this incumbent is used to meet licensure requirements, is used for statistical purposes, and for financial and billing purposes. Incumbent(s) operate under the general supervision of HIM Coding leadership.

Accountabilities

• Applies ICD and ICD-PCS codes to inpatient records, including major traumas and Neonatal Intensive Care Unit (NICU) records based on review of clinical documentation. Verifies assignment of DRGs, MCC/CCs, Hospital-Acquired Conditions (HACs), and Patient Safety Indicators (PSIs) that most appropriately reflect documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department policies and procedures. Selects the optimal principal diagnoses with appropriate POA indicator assignment and sequencing of risk adjustment diagnoses following established guidelines. - 80%
• Reviews work queues daily to identify charts that need to be coded and prioritizes as per department-specific guidelines and within designated timelines. Follows up on On-hold accounts daily for final coding. - 5%
• Identifies and requests physician queries following established guidelines when existing documentation is unclear or ambiguous following American Health Information Management (AHIMA) guidelines and established organization policies. Ensures all open queries initiated by Clinical Documentation Specialists have been addressed prior to final coding. - 5%
• Adheres to department standards for productivity and accuracy. - 5%
• Identifies and trends coding issues, escalating identified concerns to coding leadership. - 2%
• Participates in on-site, remote, and/or external training workshops and training. Attends and participates in CDI-Coding Task Force and other collaborative training and education with CDI, PFS, and Quality. - 1%
• Demonstrates proficiency in utilizing official coding books as well as the electronic medical record, computer-assisted coding/encoding software, and clinical documentation information systems to facilitate coding assignment. - 1%
• Consults, provides professional expertise to, and collaborates with clinical documentation specialists on coding and documentation practices and standards. - 1%
• Performs other duties as assigned.

Supervisory/Management Responsibilities

• This is a non-management job that will report to a supervisor, manager, director, or executive.

Minimum Requirements

• Certification Program; Associate Degree or Coding Certificate through American Health Information Management (AHIMA) or other approved coding certification program.
• 3 years of Coding experience in an acute care or ambulatory setting. Inpatient Coding Experience. Work experience may NOT be substituted for education requirement.

In Lieu Of

• In lieu of the above experience and requirements, successful completion of the IP Coder Associate program, coder associates will be accepted.

Required Certifications/Registrations/Licenses

• Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or other approved coding credential.

Knowledge, Skills, and Abilities

• Knowledge of electronic medical records and 3M or Encoder System.
• Strong knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process.
• Knowledge of MS DRG prospective payment system and severity systems.
• Ability to concentrate for extended periods of time.
• Ability to work and make decisions independently.
• EPIC health information system experience preferred.

Work Shift

Day (United States of America)

Location

Prisma Health Corporate Office

Facility

7001 Corporate

Department

70017512 HIM Coding

Share your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.