Specialist - Concurrent Coding / Inpatient Coder

Specialist-Concurrent Coding/Inpatient
Scottsdale Arizona   85258

Exp 2-5

Degree Associates

Job Summary:The Concurrent Coding Specialist performs and facilitates concurrent inpatient coding in order to establish a working DRG. Ensures high quality documentation that is thorough, accurate and complete to ensure accurate reimbursement capture. He or she will concurrently reviews health records, identifies key clinical data elements within the record, and translate this data from verbal description of disease, injuries and procedures into numerical designations, applying ICD coding systems.Audits for documentation opportunities and queries clinical staff with CDI to fill in any gaps, clarify confusing, incomplete or conflicting information and obtain any needed additional documentation in real time.  Ensures coding compliance and acts as technical resource, resolves issues, educates and works closely with Clinical Documentation Improvement Specialist. Identifies areas of documentation improvement for both ICD9 and ICD10 coding standards.  Position Accountabilities:The following are essential job accountabilities:1.        Reviews and codes accounts that need Concurrent Coding and DRG assignment. Concurrently reviews patient charts and assigns appropriate codes to diagnoses and procedures, in order to establish a working DRG.  Ensures high quality documentation that is thorough, accurate and complete to ensure accurate reimbursement capture. Reviews charts and entire medical records, assigning ICD codes to each data element. Concurrently reviews and manages the most complex coding cases. Works closely with Clinical Documentation Improvement Specialist and clinicians to capture accurate documentation. Enters findings of concurrent coding reviews into CDI Software application. Effectively uses applicable software applications to assign codes, determines a DRG and accurately enters codes into computer.Percent of Time            30%2.         Audits for documentation opportunities and queries clinical staff with CDI to fill in any gaps, clarify confusing, incomplete or conflicting information and obtain any needed additional documentation in real time.  Contacts and works with physicians as needed for clarification of details of disease process or clarification of documentation to ensure correct coding. Expedites charts as necessary to obtain additional physician documentation. Assists in obtaining required Present on Admissions documentation.Percent of Time                25%3          Records and sequences clinical data in correct order using national definitions of the Uniform Hospital Discharge Data Set (UHDDS). Applies transfer rule for correct discharge disposition of records according to established policy.Percent of Time                15%4.          Ensures coding compliance; applies all coding guidelines and principles as defined in the Coding Clinic, and leading authorities. Complies with standardized coding standards and conventions and regulations, corporate compliance standards, and reimbursement policies. Stays current on all Medicare and other Governmental payer rules/updates.Percent of Time                 10%5.         Maintains department best practice productivity and quality standards. Actively participates in DRG assurance program. Discusses coding questions with CDI team and Supervisor and reports unusual occurrences to Supervisor, Director of Health Information Management, or Compliance officer. Acts as a technical resource; facilitates problem/issue resolution. Makes suggestions and recommendations for improvements. Assists in performance of all quality initiative medical audits.Percent of Time              10% 6.    Collaborates with HIM leadership for an effective department and smoothly running process.  Covers for absences/vacations. Works professionally with all customers (MD's, departments, nursing, etc). Assists HIM management on chart audit reviews, as assigned.Percent of Time               10%7.        Performs other related duties as assigned or requested.