Inpatient Coder 2, Full Time, Days

Department: Health Information Management 

Address: 1400 NW N River Dr. Miami, 33126

Shift Details: Monday to Friday, 7.30 AM to 4 PM [Remote but open to applicants who reside in the state of Florida] 

Summary

HIM Inpatient Coder 2 is responsible for reviewing the clinical documentation contained in the in-patient medical records to accurately assign and sequence ICD-9 diagnostic and ICD-9 procedure codes to inpatient records for use in reimbursement and data collection. The HIM - In-patient Coder 2 is able to code complex cases usually resulting in numerous codes and long length of stay.

Responsibilities

• Has the knowledge and experience to code complex cases using ICD-9 and/or ICD-10 code set; including, but not limited to the following services: Trauma, Transplant, Neurosurgery, Cardiovascular Surgery, Burn Unit, and any other medical record assigned to them. 
• Ensures all accounts are coded correctly, which will provide an accurate MS-DRG or APR-DRG for appropriate reimbursement. Ensures all accounts are coded within 4 days of the patient's discharge date, meeting productivity standards according to AHIMA Guidelines depending on record type. 
• Verifies patient information to identify any discrepancies and ensures that all codes and any other abstracted information is applied to the appropriate patient's encounter. 
• While reviewing the record for coding purposes, serves as a quality reviewer, and identifies any documents not belonging to the patient, or the correct patient's encounter. 
• Ensures the accuracy when using the appropriate modifiers while coding out patient's encounters. 
• Assesses documentation and if necessary queries the physician for additional information when indicated to clarify a diagnosis, symptom or any reason for services provided, according to Coding Guidelines and Coding Clinics. 
• Makes sure all codes are utilized to reflect the care rendered to the patient which in return will ensure patient safety, accuracy of data retrieval and provides the organization with accurate reimbursement for the care provided to the patient. 
• Recognizes and reports unusual circumstances and/or information with possible risk factors to the Coding Associate Administrator or the Coding Director. 
• Meets continuing education requirements established by American Health Information Management Association (AHIMA) and/or American Association of Professional Coders (AAPC) to maintain appropriate certification and competency in job skills and knowledge. 
• Is actively involved in all ICD-10-CM-PCS education sessions provided by JHS, and any other outside entity approved by JHS.
• Shows competency according to education received. Adheres to the Standards of Excellence at all times, and respects the rights, privacy and property of others at all times including the confidentiality of information, according to Administrative Policies HIPAA Guidelines and all applicable laws and regulations. 
• Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). 
• Performs other related duties as assigned.

Experience

Generally requires 3 to 5 years of related experience.

Education

High School diploma is required.

Skill

Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines. Ability to communicate effectively in both oral and written form. Ability to handle difficult and stressful situations with critical thinking and professional composure. Ability to understand and follow instructions. Ability to exercise sound and independent judgment. Knowledge and skill in use of job appropriate technology and software applications.

Credentials

Employee hired AFTER June, 2015 must be credentialed with an HIM/Coding Credentials and/or Certification by AHIMA or AAPC.