HIM Inpatient Coding Specialist I

Accountabilities

• Examines the complete medical record to accurately determine the principal & secondary diagnoses, procedures, co-morbidities and complications demonstrating 95% accuracy as determined by audits.
• Sequences the diagnoses & procedures to obtain the optimal DRG or APR-DRG assignment and demonstrates 95% accuracy as determined by monthly audits.
• Simultaneously abstracts and enters all coded information into EPIC for timely billing.
• This includes the correct discharge disposition verified through the CRM notes available in PennChart.
• Refers charts that require clarification of vague or unclear documentation for accurate coding and DRG assignment to a Coding Quality Specialist to query the physician for the needed documentation.
• Promptly and accurately assigns Coding Hold reasons to all records that cannot be completed immediately due to: Missing Operative Notes, Missing Pathology Report, Physician Query Needed, Death Review, Discharge Disposition, Missing Other Reports (Card Cath, EPS, etc).
• Correctly identifies and applies Present on Admission indicators to all applicable diagnoses according to designated guidelines.
• Accuracy is important due to the far reaching impact on reimbursement and quality metrics.
• Consistently codes the oldest cases first and prioritizes high dollar cases over 4 days old first.
• Willing to adjust schedule to complete workload and meet pivotal revenue cycle deadlines when requested by management.
• Cooperates with departmental work volumes by adjusting work schedule.
• Strives to become fluent in the inpatient coding at all of the UPHS facilities.
• Responsible for continuing education both inside and outside the organization along with tracking Continuing Education credits to maintain professional credentials.

Minimum Requirements

• Required Education and Experience: H.S. Diploma/GED is required. Previous work experience or training in coding inpatient medical records is required. Bachelor's Degree Health Information Management or a related field is preferred.
• Licenses, Registrations, and Certifications: Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) is preferred. Certified Coding Specialist (CCS) is required.