Inpatient Coding Apprentice

Job Description

The Inpatient Coding Apprentice will:

• Evaluate medical records and documentation to ensure completeness, accuracy, and compliance with ICD-10-CM, HCPCS, CMS documentation requirements, and CPT.
• Identify diagnoses, CPT procedures, and PCS procedures relative to the patient’s encounter.
• Select the principal diagnosis and procedure, along with other diagnoses and procedures using UHDDS definition.
• Ensure appropriate DRG assignment.
• Abstract appropriate information from the complex medical record.
• Identify and report documentation issues.
• Solicit clarification from the physician regarding ambiguous or conflicting documentation in the medical record.
• Ensure all coding complies with ethical coding standards/guidelines and regulatory requirements.
• Maintain strictest confidentiality; adhere to all Health Insurance Portability and Accountability Act guidelines/regulations.
• Provide technical guidance and training on medical coding to physicians and staff.

Qualifications

• High school diploma or equivalent required.
• Must have de-escalation training completed by the end of position orientation (90 days).
• Experience in medical terminology and anatomy/physiology preferred.

Physical Demands

• Mainly sedentary work involving sitting most of the time.
• Regular requirements to move about the office, move about the facility, and travel to another facility within the SRHS service area.
• Exerting a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body.
• Substantial movements of the wrists, hands, and/or fingers while operating standard office equipment such as a computer keyboard.
• Close visual and acuity, and the ability to adjust the eye to bring an object into sharp focus, i.e., shift gaze from viewing a computer monitor to forms/printed material that are closer to compare data at close vision.
• Active for extended periods of time without experiencing undue fatigue.
• Work involves being able to perceive the nature of sound at normal speaking levels with or without correction; the ability to make fine discriminations in sound.
• Must be able to work schedules assigned with the understanding that changes may be instituted according to the needs of the hospital for off days, shifts, or weekends.

Mental Demands

• Demonstrate keen mental faculties/assessment and decision-making abilities.
• Demonstrate superior communication/speaking/enunciation skills to receive and give information in person and by telephone.
• Demonstrate strong written and verbal communication skills.
• Demonstrate emotional stability conducive to dealing with high stress levels.
• Work under pressure and meet deadlines.
• Attention to detail and the ability to multi-task in complex situations is required.
• Maintain collaborative and respectable working relationships throughout SRHS and other organizations.

Special Demands

• Possess superior customer service skills and professional etiquette.
• Possess proficient knowledge and ability to use a computer (must be keyboard proficient) and other office technology (i.e., telephone, fax, etc.), MS Outlook and Word.