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Job Summary
Reporting to the HIM Manager Coding and Education this position will provide education primarily to the Prisma Health coding staff and indirectly to Clinical Documentation Integrity (CDI) staffs, clinicians, billers and other appropriate hospital personnel. Collaborate with the HIM coding leadership to develop educational programs to ensure coders develop and sustain proficient understanding of all coding regulations, quarterly and annual coding updates, applicable clinical knowledge, and national, fiscal intermediary and organizational specific coding and reimbursement guidelines. To perform charge capture and coding by assigning International Classification of Diseases-Clinical Modification (ICD-CM), International Classification of Diseases-Procedure Coding System (ICD-PCS) codes as well as the Diagnosis Related Group (DRG) assignment, Major Complications and Comorbidities/Complications and Comorbidities (MCC/CCs) and Hospital-Acquired Condition/Patient Safety Indicator (HAC/PSI) capture as appropriate through documentation validation. Adhere to Prisma Health Coding and Compliance policies and procedures for assignment of complete, accurate, timely and consistent codes; periodically code medical records.Essential Functions
Collaborates with Coding and Revenue leadership to develop and maintain coding curriculum, education, training and other materials; train coders.
Works in conjunction with Coding leadership teams to develop annual Coding goals and objectives and audit calendar.
Works in conjunction with Coding leader to ensure continuous feedback and re-education if necessary; makes recommendations to the Coding Leadership Team when audits identify need for individualized focused audits. Presents risk assessment of findings and develop, presents and carried forward individualized educational plans to improve coder productivity and accuracy. Perform quality assurance reviews to assess comprehension of training efforts.
Periodically codes all Inpatient visit types/records based on review of clinical documentation. Queries physician following established guidelines when existing documentation is unclear or ambiguous following American Health Information Management Association (AHIMA) guidelines and established policy. Ensures all open queries initiated by Clinical Documentation Specialists have been addressed prior to final coding. Consults, provides professional expertise to and collaborates with clinical documentation specialists on coding and documentation practices and standards.
Participates in a variety of committees and groups, acting as a representative of Health Information Management (HIM) and addressing documentation, data integrity and other coding issues.
Reviewing auditing medical records to identify trends coding issues escalating identified concerns to coding leadership.
Participates in on site, remote and/or external training workshops and training. Attends and participates in CDI-Coding Task Force and other collaborative training and education with CDI, PFS and Quality.
Demonstrates proficiency in utilizing official coding books as well as the electronic medical record, computer assisted coding/encoding software, and clinical documentation information systems to facilitate coding assignment.
Adheres to department standards for productivity and accuracy.
Performs other duties as assigned.
Supervisory/Management Responsibilities
This is a non-management job that will report to a supervisor, manager, director or executive.
Minimum Requirements
Education - Associate's degree or Coding Certificate through approved American Health Information Management (AHIMA) or other coding certification program.
Experience - Four (4) years of coding experience in an acute care or ambulatory setting. Work experience may NOT be substitute for education requirement; education and/or coder training experience preferred; inpatient and outpatient experience required.
In Lieu Of
NA
Required Certifications, Registrations, Licenses
Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC) or other approved coding credential.
Knowledge, Skills and Abilities
Knowledge of electronic medical records and 3M or Encoder System.
EPIC health information system experience. Preferred.
Strong knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process.
Knowledge of MS DRG prospective payment system and severity systems.
Ability to concentrate for extended periods of time.
Ability to work and make decisions independently.
Work Shift
Day (United States of America)Location
CorporateFacility
7001 CorporateDepartment
70017512 HIM-CodingShare your talent with us! Our vision is simple: to transform healthcare for the benefits of the communities we serve. The transformation of healthcare requires talented individuals in every role here at Prisma Health.