Inpatient Coding / Abstraction Specialist Hybrid Work Environment

Hospital for Special Care; New Britain (CT); Hybrid; USD 70,000 - 90,000; Full time

Job summary

Hospital for Special Care is seeking an experienced Health Information Management coder to ensure accurate inpatient coding and DRG assignment. The role requires proficiency with ICD-9/ICD-10, CPT, HCPCS and modifier usage, and collaboration with clinicians to improve documentation.

Responsibilities include abstracting records, educating staff, and managing denials while staying current with coding guidelines and EMR systems. The position offers a hybrid schedule and a supportive HIM team.

Qualifications

• Associate degree or equivalent in health information management.
• CCS/CCS-P or CPC-P certification or able to obtain within 2 years of hire.
• Proficient with ICD-9/ICD-10, CPT, HCPCS and modifiers; must read and interpret coding books.

Responsibilities

• Abstract clinical information from medical records and assign ICD-10 diagnoses and procedure codes.
• Educate clinical staff on documentation practices and DRG assignments.
• Collaborate with hospital leadership to resolve denials and improve coding accuracy.
• Maintain knowledge of coding guidelines, DRG changes, and regulatory requirements.
• Attend training and stay current with EMR and 3M tools.

Skills

Problem solving

Written communication

Verbal communication

Reading comprehension

Education

Associate degree in health information management

RHIT certification (plus)

CCS/CCS-P/CPC-P certification

Tools

3M HDM

3M applications

Electronic Medical Record (EMR)

Coding Guru

Job description

Position Location

Hospital for Special Care

Scheduled Weekly Hours

40

Work Shift

First Shift

Department

Health Information Management

We are dedicated to creating an environment of care and engagement that makes us one of the most desirable places to work, providing exceptional care to each patient each and every day!

Qualifications

• Required: Associate’s degree in health information management or equivalent from two-year college. Minimum 3 years coding inpatient records in acute or acute/long term care setting. Years of experience in coding may be considered as substitute for education. Experience with coding outpatient/ clinic records desirable.
• Required: Certified Coding Specialist (CCS) or Certified Coding Specialist – Physician-based (CCS-P), or Certified Professional Coder-Payer (CPC-P), or able to achieve certification within 2 years of hire.
• Required: Ability to read, analyze, interpret ICD-9, ICD-10, CPT, HCPCS and Modifier books. Ability to document and follow-up on Discharged Not Final Billed (DNFB) reports and to effectively present information and respond to questions from Administration, Physicians, and committee members. Can effectively describe when and how to use modifers on CPT codes to physicians and other healthcare providers. Understands denials and how to solve them.
• Required: Must be proficient in Anatomy and Physiology, Medical Terminology, and 3M applications. Past experience using 3M HDM report writer a plus. Must be familiar with a hybrid medical record and working with an electronic medical record. Must have experience with proper DRG assignment.
• Preferred: Experience with coding outpatient/ clinic records
• Preferred: Registered Health Information Technician (RHIT) certification is a plus.

Job Summary

Responsible for the coding and facility charge process for inpatient accounts, may assist from time to time with outpatient coding. Abstracts clinical information from medical records and assigns appropriate ICD 10 diagnoses and procedure codes as appropriate and CPT modifiers according to coding guidelines and established procedures. Educates both medical and clinical staff on appropriate documentation practices, DRG assignment and changes in assignments, modifier usage, changes in software upgrades and communicates guidelines as published by regulatory agencies. Works closely with clinical documentation improvement initiatives and patient accounts to ensure documentation accurately reflects patient acuity for services rendered.

PHYSICAL DEMANDS

• This position requires walking, standing, and sitting with the ability to lift/carry and push/pull weights of 11-20 pounds frequently.
• This position also requires the ability to squat, kneel, balance, reach forward and above shoulders, twist, and hear frequently.
• The ability to touch and see are required continuously with gross grasp and fine manipulative maneuvering required continuously.

COGNITIVE DEMANDS

• This position requires solid skills in problem solving and written expression and communication, thorough skills in verbal expression/communication and extensive skills in reading and auditory comprehensive.
• Ability to add and subtract two-digit numbers and to multiply and divide with 10’s and 100’s.
• Ability to perform these operations using units of American money and weight measurement, volume and distance.
• Ability to solve practical problems and deal with a variety of concrete variables in situation where only limited standardizations exist.
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

WORK DEMANDS

• This position requires the ability to work independently as well as with others.
• Stays current with official coding guidelines for both inpatient and outpatient coding.
• Stays abreast of any regulatory changes regarding the assignment of ICD-9, ICD-10, HCPCS, CPT and modifier assignment.
• Takes initiative to read relevant professional journals.
• Stays current with all continuing education certification requirements relating to coding certification.
• This position works a hybrid schedule.

Essential Functions

• Ensures that coding processes can be completed timely and efficiently for admission and discharged inpatient records. Working with HIM and other staff to identify and resolve outstanding accounts that require documents in order to completely code.
• Prepares daily outstanding coding report and distributes as appropriate.
• Assigns admission DRG for all admitted patients within 24 hours, reports to Case Management and Admitting
• Uses EMR, 3m HDM abstracting, coding and reference tool, along with clinical documentation tool to assign all diagnostic, procedure and facility-based charging in a timely manner. Works in collaboration with others using Coding Guru to ensure proper use of modifier assignment to CPT codes for inpatient and outpatient procedures or services.
• Resolves outstanding edits and denials for assigned case load weekly. Communicates to clinicians to resolve issues. Follows up with providers for any records which cannot be completed for lack of documentation or clarification. Distributes coding queries as appropriate.
• Provides information/training to clinical staff and providers on changes in coding practices such as ICD-10, CPT and modifiers, appropriate documentation practices, and DRG assignments as needed.
• Assists with updating departmental coding policies and procedures. Serves as a resource for all hospital staff with questions related to Inpatient ICD 9/10 coding, CPT modifier and DRG assignments.
• Participates in training, updates and knowledge-based review on utilizing the Electronic Medical Record to maximize efficient use for coding.
• Maintains knowledge of Inpatient coding practices and procedures. Maintains knowledge of Federal, State, and JC standards of documentation regulations and guidelines. Maintains and keeps coding credentials current.