Health Information Management Specialist Level I

Duties & Responsibilities

• Validates the completeness, accuracy, and specificity of code assignments for inpatient, outpatient, and ambulatory surgery records in accordance with established coding guidelines.
• Ensures that all documented diagnoses and procedures are properly coded.
• Validates the accuracy of DRG assignment.
• Validates the accuracy of additional information abstracted from the clinical record.
• Maintains data integrity and accuracy; makes necessary data corrections and entry.
• Performs chart review to determine data quality.
• Identifies and reports on cases with documentation inadequacies, inconsistencies, and other issues with opportunities for improvement.
• Evaluates root causes and proposes corrective action for same.
• Generates physician queries as needed in order to obtain clarification of medical record documentation.
• Validates that physicians have been queried according to established procedure.
• Confers with coding specialists and oversees and evaluates work performance.
• Provides ongoing and specific feedback to coding staff and management team regarding review findings.
• Provides education and training to new and existing health information management staff.
• Instructs physicians, nurses, health information management staff, and other appropriate personnel regarding documentation requirements as related to coding.
• Works with other departments to ensure that accurate reporting and reimbursement are facilitated.
• Sets up and maintains codes for diagnoses and procedures according to the current classification system for inpatient, outpatient, and ambulatory surgery records and in accordance with established coding guidelines.
• Performs concurrent and retrospective clinical documentation review and provides data when necessary.
• Reviews and analyzes clinical records for compliance with appropriate regulatory requirements.
• Effectively utilizes computer applications and other coding and abstracting software and hardware as necessary.

Requirements

• Possession of a Registered Health Information Administrator (RHIA) credential from AHIMA and two (2) years of satisfactory experience in coding and abstracting medical records in a recognized hospital or health care organization, of which one (1) year has been in a supervisory and/or administrative capacity;
• or Possession of a Registered Health Information Technician (RHIT) credential from AHIMA and four (4) years of satisfactory experience in coding and abstracting medical records in a recognized hospital or health care organization, of which two (2) years have been in a supervisory and/or administrative capacity;
• or Possession of a valid certificate as a Certified Coding Specialist (CCS) from AHIMA and six (6) years of satisfactory experience in coding and abstracting medical records in a recognized hospital or health care organization, of which three (3) years have been in a supervisory and/or administrative capacity;
• A satisfactory equivalent of education and experience.

Qualifications

Minimum Qualifications:

• Possession of a Registered Health Information Administrator (RHIA) credential from AHIMA and two (2) years of satisfactory experience in coding and abstracting medical records in a recognized hospital or health care organization, of which one (1) year has been in a supervisory and/or administrative capacity;
• or Possession of a Registered Health Information Technician (RHIT) credential from AHIMA and four (4) years of satisfactory experience in coding and abstracting medical records in a recognized hospital or health care organization, of which two (2) years have been in a supervisory and/or administrative capacity;
• or Possession of a valid certificate as a Certified Coding Specialist (CCS) from AHIMA and six (6) years of satisfactory experience in coding and abstracting medical records in a recognized hospital or health care organization, of which three (3) years have been in a supervisory and/or administrative capacity;
• A satisfactory equivalent of education and experience.

Skills

Not specified

Benefits

Not specified

Pay

Not specified

Schedule

Not specified