Employment Type:

Shift:

Description:

I Accountability Objectives:

Reviews medical record documentation concurrently or retrospectively to code and abstract diagnostic and procedural information. Collaborates with Clinicians on a concurrent basis to review and analyze the medical record documentation. Makes recommendations to improve the quality of clinical documentation and to support accurate and timely DRG assignment.

II Position Qualifications:

Minimum Education, Licensure / Certification and Experience Required.

A. Education

High school graduate or equivalent.
College degree preferred.

B. Licensure / Certification

Currently registered as Health Information Technician (RHIT) OR Registered Health Information Administrator (RHIA) OR Certified Coding Specialist (CCS) OR Certified Coding Associate (CCA) OR Certified Physician Coder (CPC).
CCS or CCA preferred.
C Special Skill / Aptitudes

Must be familiar with encoding and grouper software.
Successfully demonstrate knowledge application using coding samples.
Interpersonal skills to communicate effectively with the medical staff and hospital personnel.
Excellent customer service orientation skills necessary in order to deal effectively with various levels of hospital personnel, outside customers and community groups.

D. Experience

Minimum of two years' work in a hospital coding environment.
The work experience must be within the most recent eighteen (18) months.
ICD-9-CM and CPT-4/HCPC required.
ICD-10-CM and ICD-10-PCS preferred.
III Duties / Responsibilities:

Reviews the complete inpatient or outpatient medical record documentation to identify and code diagnostic and procedural information using ICD-9-CM, CPT-4/HCPCS, ICD-10-CM and ICD-10-PCS classification systems.
Works collaboratively with Clinicians and Clinical Documentation Specialists to provide analysis of documentation for clinical support of diagnoses/quality indicators and applies strategies for clinical documentation improvement to support accurate and timely DRG Assignment.
Works collaboratively with Clinical Documentation Specialists to ensure query documentation with clinical support has been provided by the clinicians. Assists tracking of query documentation success.
Identifies patient safety errors within the electronic medical record (i.e. wrong encounter, wrong patient, scanning errors, physician documentation errors)
Works independently in coding as a remote associate. Troubleshoots and assists analysis of system issues independently with TIS assistance.
Works collaboratively with Clinicians for analysis of documentation to support accurate and timely CPT and APC Assignment.
Utilizing 3M ARMS on outpatient medical records, analyzes charges for edits and refers accounts back to departments for charge and/or modifier correction to ensure an accurate claim at time of billing.
Performs other duties as assigned.
Demonstrates and actively promotes an understanding and commitment to the mission of St. Joseph Mercy Oakland through performing behaviors consistent with the Trinity Health Values.
Maintains a working knowledge of applicable Federal, State, and Local laws and regulations, the Trinity Health Organizational Integrity Program, including the Standards of Conduct, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behaviors.
Supports and conducts one's self in a manner consistent with customer service expectations.
In accordance with unit or departmental practice, determines that appropriate charges have been entered for the correct patient, encounter, date/time of service, with any required modifiers. Make corrections as needed per charge capture policy/practice.
In accordance with unit or departmental practice, actively participates in on-going education and communication regarding revenue management.
In accordance with unit or departmental practice, assists with tracking and monitoring of equipment assigned to the unit. Requests services for maintaining equipment as needed.
In accordance with unit or departmental practice, proficient with the electronic health records for documentation, assessment, and care management, performing these activities concurrently with provision of care throughout the shift.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.