HIM Coder III - Remote

Salem Health Hospitals & Clinics; Tucson, Northern (AZ, KY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Salem Health Hospitals & Clinics seeks an experienced inpatient facility coder to assign ICD-10-CM/PCS and CPT/HCPCS codes for diagnoses and procedures based on medical records. The role requires five years in acute care coding and professional certifications.

You will use 3M 360, CAC, Epic, and related tools to ensure accurate coding, while maintaining compliance with UHDDS sequencing and DRG/APC guidelines.

Qualifications

• Must have completed a 2-year college or technical school curriculum in Health Information Management; a 4-year degree is preferred.
• Minimum of five years acute care hospital coding experience.
• RHIT, RHIA, CCS, CCS-P, CPC, CIC or COC certifications required or eligible.

Responsibilities

• Assigns correct ICD-10-CM/PCS and CPT/HCPCS codes to diagnoses and procedures based on medical records.
• Code inpatient and outpatient records; outpatient coding includes at least four areas independently (ER, same-day surgery, observation, pain clinic, wound clinic, diagnostics, recurring accounts).
• Follow current coding guidelines to ensure consistent and accurate coding of data.
• Utilize 3M 360, CAC, Epic and other applications to ensure coding accuracy.
• Ensure provider documentation supports coding and reimbursement; request clarification when information is incomplete.
• Determine the sequence of diagnoses per UHDDS standards.
• Input abstract data and codes into computer systems for distribution to payers and regulators.
• Maintain knowledge of coding conventions and policies; maintain current knowledge of guidelines.

Skills

ICD-10-CM/ICD-10-PCS knowledge

UHDDS sequencing

DRG/APC knowledge

Medical terminology

CPT/HCPCS coding

Documentation interpretation

Communication skills

Education

Associate degree in Health Information Management

Bachelor's degree in Health Information Management (preferred)

Tools

3M 360

CAC

Epic

Job description

Seeking Inpatient Facility Coders

SUMMARY:

Provides timely and accurate administrative and clinical data through the accurate assignment of current ICD-10-CM/PCS, CPT or HCPCS codes while complying with the regulations and requirements of the Federal Government, State licensing agencies and the Hospital’s policies and procedures. Supports TMCH’s management planning process and ensures appropriate reimbursement for services.

ESSENTIAL FUNCTIONS:

Assigns the correct ICD-10-CM, ICD-10-PCS, CPT or HCPCS codes to each diagnosis and operative procedure substantiated by documentation contained in the medical record utilizing the current code sets.

Responsible for accurately coding inpatient or outpatient record types. For outpatient, must be able to code a minimum of four of the following independently: emergency, same day surgery, observation, pain clinic, wound clinic, diagnostics and recurring accounts.

Follows departmental and current official coding guidelines to ensure consistent and accurate coding of diagnostic and procedural data.

Utilizes the 3M 360, CAC (Computer Assisted Coding), Epic, and any other necessary applications for proper coding, ensuring accuracy.

Ensures that the medical staff documents have sufficient information for accurate coding and appropriate reimbursement, requesting clarification from the provider when information is incomplete. Assists physicians, their office staff, quality management and other hospital personnel with coding and DRG/APC questions.

Determines the sequence of diagnoses according to UHDDS (Uniform Hospital Discharge Data Set) standards.

Inputs abstract data and codes into computer to gather administrative and clinical data for distribution to outside regulatory agencies, third party payers, administrative staff and physicians.

Ensures that institutional policies and procedures for maintenance of medical records are followed. Maintains current knowledge of coding principles and guidelines as coding conventions are updated.

Maintains a 95% coding accuracy rate. Achieves average weekly utilization productivity of 95% of standard.

Reviews charts that have been returned by payers for challenges.

Adheres to TMC organizational and department‑specific safety, confidentiality, values, policies and standards.

Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION

Completion of a 2-year college or technical school curriculum in Health Information Management, or an equivalent combination of relevant education and experience. Preferred is the completion of a 4-year college curriculum in Health Information Management.

EXPERIENCE

Five (5) years of acute care hospital coding experience required.

LICENSURE OR CERTIFICATION

Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS), or Certified Coding Specialist-Physician-based (CCS‑P), or Certified Professional Coder (CPC), or Certified Inpatient Coder (CIC) or Certified Outpatient Coder (COC).

KNOWLEDGE, SKILLS AND ABILITIES:

• Knowledge of current ICD-10-CM and ICD-10-PCS codes, APC reimbursement models, UHDDS sequencing and DRG payment methodologies, including both MS-DRGs and APR-DRGs.
• Knowledge of medical terminology.
• Skill in the coding of medical information and maintaining databases to ensure accuracy.
• Skill in organizing tasks to ensure the timely and accurate coding of information.
• Skill in both oral and written communication.
• Ability to read, analyze and interpret professional journals, governmental regulations, and coding guidelines.
• Ability to follow written and verbal instructions.
• Ability to maintain good working relationships and communication with the medical staff, nursing, administration, and other ancillary departments with the hospital.
• Ability to perform multiple tasks and ensure completion to meet strict deadlines.