CODER III

CODER III 

3-5 years experience preferred

Provides high level technical competency and subject matter expertise analyzing physician/provider

documentation contained in assigned Complex Outpatient (CO) and Inpatient health records (electronic,

paper and hybrid) to determine the principal diagnosis, secondary diagnoses, principal procedure and

secondary procedures. Provides appropriate Medical Severity Diagnostic Related Groups (MS-DRG),

Present on Admission (POA), Severity of Illness (SOI) & Risk of Mortality (ROM) assignments for

Inpatient records and accurate APC assignments and all required modifiers for Complex Outpatient

records.

Utilizes encoder software applications, which includes all applicable online tools and references in the

assignment of International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM)

diagnosis and procedure codes, Current Procedural Terminology (CPT)-4®/ Healthcare Common

Procedure Coding System (HCPCS) procedure codes, MS-DRG, POA, SOI & ROM assignments and

assignment of APC's and all required modifiers.

Utilizes coding guidelines established by the Centers for Medicare/Medicaid Services (CMS), American

Hospital Association (AHA) Coding Clinic for ICD-9-CM, American Medical Association (AMA) for CPT-4

codes and CPT Assistant, American Health Information Management Association (AHIMA) Standards of

Ethical Coding, Unified Revenue Organization/Ministry Organization (URO/MO) coding policies and

Trinity Health Coding Manual (TBA).

SKILLS AND CERTIFICATIONS

Bachelor's Degree in HIM preferred

Registered HIT and/or Certified Coding Specialist (CCS) preferred

Registered HIA preferred

1 year experience coding INPATIENT records 

IDEAL CANDIDATE

The ideal candidate has at least 1 year experience coding inpatient records in an acute setting. Although the job description requires only an Associates, we are really looking for someone who a) has a Bachelor's degree in HIM, b) is a Registered Health Information Technician (RHIT), c) is a Certified Coding Specialist (CCS), or d) is a Registered Health Information Administrator (RHIA).

IDEAL CANDIDATE SHOULD HAVE WORKED FOR THE FOLLOWING COMPANY(IES): Other healthcare organizations comparable in size with acute inpatient coding experience.