Inpatient Coder - Community Hospital
About the role
The Coder will review clinical documentation to assign and sequence diagnostic and procedural codes for Facility Inpatient records to meet the needs of hospital data retrieval for billing and reimbursement. Coder validates MS-DRG calculations to accurately capture the diagnoses and procedures documented in the clinical record. Coder performs documentation review and assessment for accurate abstracting of clinical data to meet regulatory compliance requirements. Coder may interact with client staff and providers.
Responsibilities
- Select and sequence ICD-10 CM and PCS codes for designated patient types which may include but is not limited to: Acute Facility Inpatient for Non-Teaching Level facilities.
- Review and analyze clinical records to ensure that MS-DRG assignments accurately reflect the diagnoses/procedures documented in the clinical record.
- Abstract clinical data from the record after documentation review to ensure that it is adequate and appropriate to support diagnoses, procedures and discharge disposition is selected.
- Complete assigned work functions utilizing appropriate resources.
- Maintain strict patient and provider confidentiality in compliance with HIPAA.
- Participate in client and staff meetings, trainings, and conference calls as requested and/or required.
- Maintain current working knowledge of ICD-10 CM and PCS and coding guidelines, government regulations, protocols, and third-party requirements regarding coding and/or billing.
- Participate in continuing education activities to enhance knowledge, skills, and maintain current credentials.
- Support Savista’s Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by in-service attendance and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient and/or client information.
- Perform other related duties as assigned or requested.
Requirements
Candidates must successfully pass pre-employment skills assessment. An active AHIMA (American Health Information Association) credential including but not limited to RHIA, RHIT, CCS or an active AAPC (American Academy of Professional Coders) credentials COC (formerly CPC-H), CCS-P, or CPC or related specialty credential. Two (2) years of recent and relevant hands-on coding experience with all record types: Acute Inpatient.
Qualifications
- Active AHIMA (American Health Information Association) credential including but not limited to RHIA, RHIT, CCS or an active AAPC (American Academy of Professional Coders) credentials COC (formerly CPC-H), CCS-P, or CPC or related specialty credential.
- Two (2) years of recent and relevant hands-on coding experience with all record types: Acute Inpatient.
Skills
Knowledge of ICD-10 CM and PCS and coding guidelines, government regulations, protocols, and third-party requirements regarding coding and/or billing. Ability to maintain strict patient and provider confidentiality in compliance with HIPAA. Ability to participate in continuing education activities to enhance knowledge, skills, and maintain current credentials. Ability to support Savista’s Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by in-service attendance and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient and/or client information.
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