Inpatient Coder: Precise Medical Coding & Data Abstraction

NALHE; Roseville (CA); Sur place; USD 70 000 - 110 000; Plein temps

Résumé du poste

NALHE is seeking an Inpatient Coder in California (Roseville) to accurately code and abstract inpatient diagnoses, procedures and services from medical records using ICD-CM/ICD-PCS, CPT and HCPCS guidelines.

You will work with physicians to clarify documentation, ensure data integrity and DRG accuracy, meet productivity/quality standards, and protect patient confidentiality in a fast-paced hospital setting.

Qualifications

Responsabilités

• Coding and Abstracting: Reviews medical record documentation to identify diagnoses/procedures to be coded.
• Independently organizes and prioritizes work assignments to ensure that records are coded timely and compliantly in conformance with regulatory requirements.
• Codes all appropriate diagnosis and procedures from the medical record using ICD-CM, ICD-PCS, CPT and HCSPCS coding classification systems.
• Responsible for the sequencing of diagnoses and procedures in accordance with guidelines outlined in ICD-CM, ICD-PCS, CPT, Uniform Hospital Discharge Data Set, Medicare regulations and other appropriate classification systems.
• Determines that the DRG is appropriate for each case and reviews DRG discrepancies to ensure appropriate group of each case.
• Verifies and abstracts the appropriate data from the medical records to meet requirements for data submission and reporting.
• Corrects data when needed.
• Ensures that all data abstracted is consistent with guidelines outlined by TJC, OSHPD, CMS and regional and local KP policies.
• Ensures the accuracy and integrity of data abstracted and coded based upon medical record documentation prior to data submission or coding completion.
• Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
• Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the Inpatient Coder position.
• Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
• Ensures timely data completion by meeting coding/abstracting productivity/quality standards established for the Inpatient Coder position.
• Confidentiality/Security of Systems: Maintains and complies with policies and procedures for confidentiality of all patient records.
• Demonstrates knowledge of privacy and security of systems and associated policies and procedures for maintaining the security of the data contained within the systems.
• Other Duties: Performs other duties as assigned.

Description du poste

NALHE is seeking an Inpatient Coder in California (Roseville) to accurately code and abstract inpatient diagnoses, procedures and services from medical records using ICD-CM/ICD-PCS, CPT and HCPCS guidelines.

You will work with physicians to clarify documentation, ensure data integrity and DRG accuracy, meet productivity/quality standards, and protect patient confidentiality in a fast-paced hospital setting.