Clinical Documentation Coding Specialist II

About the role

As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission.

This position provides inpatient facility coding and Clinical Documentation Improvement (CDI) support in the Health Information Management department with minimal educational intervention required.

The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience. Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.

Responsibilities

• Performs thorough review of medical record for identification of relevant clinical diagnoses and procedures performed.
• Assigns appropriate ICD-CM principal diagnosis code.
• Assigns appropriate ICD-CM secondary diagnosis codes.
• Assigns appropriate ICD-10 PCS code(s).
• Sequences principal and secondary diagnoses codes and primary procedure code for accurate MS-DRG and APR-DRG assignment.
• Assigns Present on Admission (POA) indicator for each diagnosis code.
• Abstracts required data elements, including but not limited to: Admit Type, Admit Source / Point of Origin, and Discharge Disposition.
• Expands understanding / identification of opportunities where additional provider documentation is required to thoroughly and accurately assign ICD-10 code.
• Understands and adheres to compliant provider query practices and procedures.
• Understands and adheres to Health Information Coding policies and Official Coding Guidelines, as published by CMS and Cooperating Parties.

Skills

• Proficient knowledge of medical terminology, anatomy & physiology and pathophysiology.
• Knowledge of basic coding conventions & use of coding nomenclature.
• Developing knowledge of health care quality related initiatives.
• Demonstration of acceptable progression through service lines of increasing complexity.
• Achieve and sustain acceptable productivity rate as defined by Coding Leadership.
• Ability to effectively communicate with clinical staff and other hospital department personnel.
• Knowledge of healthcare IT systems, preferably Epic and 3M 360 Encompass R2.
• Knowledge of Microsoft Office.
• Team player, ability to collaborate with colleagues and leadership.

Requirements

• Minimum of three (3) years of experience coding inpatient facility (HB).
• One of the following current certifications: RHIA, RHIT, or CCS from the American Health Information Management Association (AHIMA).
• Additional license requirements as determined by the hiring department.

Preferred Qualifications

• Bachelor's or Associate's degree in a related field.

Working Conditions

This is a sedentary position in an office setting that may exert up to 10 pounds and may lift, carry, push, pull or otherwise move objects. This position involves sitting most of the time and is not exposed to adverse environmental conditions. Employee must be able to meet the following requirements with or without an accommodation.

Physical Requirements

• Listening
• Sitting
• Speaking