Clinical Documentation Coding Specialist III

Responsibilities

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

Requirements

• Minimum of four (4) years of experience coding inpatient facility (HB).
• Licenses Required:
• Current RHIA Certification with the American Health Information Management Association (AHIMA).
• Current RHIT Certification with the American Health Information Management Association (AHIMA).
• Current CCS Certification with the American Health Information Management Association (AHIMA).
• Preferred Qualifications:
• Experience at Level 1 Trauma facility coding inpatient HB.
• Bachelor's or Associate's degree in a related field.

Qualifications

• Proficient knowledge of medical terminology, anatomy & physiology and pathophysiology.
• Proficient knowledge of coding conventions & use of coding nomenclature.
• Proficient in all service lines of varying complexity.
• Working knowledge of health care quality related initiatives.
• 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.
• Ability to effectively mentor entry-level staff.