Senior Outpatient Coder

About the role

At Houston Methodist, the Senior Outpatient Coder is responsible for ensuring diagnostic and procedure codes are assigned accurately to day surgery and observation encounters based upon documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines. FLSA status: Non-exempt.

Qualifications

Education

• Associate’s or higher degree in a Commission on Accreditation for Health Informatics and Information Management accredited program
• Or additional two years of experience (in addition to the minimum experience requirements below) in lieu of degree

Experience

• Three years of relevant outpatient coding experience
• Or successful completion of the Houston Methodist Senior Outpatient Coder Transition Program

Licenses and Certifications (required — one of the following)

• RHIT – Certified Health Information Technician (AHIMA)
• RHIA – Registered Health Information Administrator (AHIMA)
• CCS – Certified Coding Specialist (AHIMA)
• CCA – Certified Coding Associate (AHIMA)
• CCS-P – Certified Coding Specialist Physician-Based (AHIMA)
• CPC – Certified Professional Coder (AAPC)

Skills and Abilities

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing English to perform essential functions, especially activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members, and co-workers with a customer service focus and positive language principles
• Knowledge of coding classification systems, DRG and APC systems, official coding guidelines, and coding compliance
• Knowledge of electronic medical record and imaging systems
• Working knowledge of medical terminology, anatomy, and physiology
• Proficiency with electronic encoder application
• Extensive PC knowledge — able to work effectively in common office software, coding software, and abstracting systems

Responsibilities

People

• Interacts and communicates effectively with members of the coding team and appropriate stakeholders
• Participates and provides feedback during coding section meetings and coding education in-services
• Takes initiative to assist others and shares knowledge with appropriate stakeholders

Service

• Responds promptly to internal and external customer requests
• Responds promptly and appropriately to requests to code or review coded accounts for accuracy
• Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process

Quality / Safety

• Assigns diagnostic and procedural codes to encounters of high complexity
• Maintains and achieves departmental standards of coding quality by assigning accurate ICD-10-CM/ICD-10-PCS and CPT codes and APC assignment using an electronic encoder application in accordance with hospital policy and regulatory body guidelines
• Maintains and achieves departmental standards of abstracting quality by reviewing discharge disposition entered by nursing and correcting if necessary to achieve highest quality of entered data
• Assigns and enters physician identification number and procedure date correctly in the medical record abstracting system
• Reviews medical record documentation and abstracts data into the encoder and EHR to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions, and procedures
• Utilizes all tools and resources for accuracy
• Complies with the Standards of Ethical Coding as set forth by AHIMA and adheres to official guidelines

Finance

• Utilizes time effectively
• Consistently codes and abstracts at or above departmental standards of productivity while ensuring accuracy
• Supports meeting organizational goal for Accounts Receivable (AR) associated with uncoded accounts
• Maintains coding timeframes within established departmental standards by ensuring all work items assigned to coding queues are processed timely

Growth / Innovation

• Critically evaluates own performance, accepts constructive criticism, and looks for ways to improve
• Displays initiative to improve relative to job function
• Contributes ideas to help improve quality of coding data and abstracting data

Supplemental Requirements

Work Attire

• Uniform: No
• Scrubs: No
• Business professional: Yes
• Other (department approved): No

On-Call

Not required. Note: employees may be required to be on-call during emergencies (e.g., disaster, severe weather events) regardless of selection.

Travel

• May require travel within the Houston Metropolitan area
• May require travel outside Houston Metropolitan area