HIM Hospital Coder II

As needed, Coders II may assist and be a resource for data integrity for other employees who need clarification and assistance in coding.

Positions assigned to this classification are differentiated from those assigned to the Hospital Coder I classification in that only the former are typically characterized by the performance of a higher, more complex and responsible level of work generally associated with - but not limited to - the coding of in-patient Medicare medical records / data.

• Coders II also differ from Coders I in the type and amount of supervision received; responsibility for data comprehensiveness and quality assurance;
• direction provided to other staff; data analysis, knowledge of procedures related to the sequencing of diagnoses and interventions, as well as data management policies and procedures;

required quantity and quality performance standards.

Education / License / Certification :

• This position requires certification as a Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA).
• Completion of classes in medical terminology, anatomy and physiology, ICD-10 and CPT coding conventions, and disease process from an accredited program.
• Must have high school diploma or GED.

Qualifications :

• Must have at least three (3) years hospital inpatient experience coding within the last five years. Demonstrated ability to understand the clinical content of a health record, including the most complicated records
• Must also be able to communicate with physicians in order to clarify diagnoses / procedures and sequencing of diagnoses.

Ability to demonstrate knowledge of and utilize auditing skills related to coding quality and compliance

• Must be able to meet quantity and quality standards established for Coders II.
• Must be able to pass coding test at %.
• Basic PC skills.
• Must maintain a minimum of ten (10) CE units annually. Must maintain current coding credential.
• Will abide by the AHIMA coding code of ethics.

Physical and Mental Demands :

• Ability to sit for long periods of time.
• Ability to lift, push or pull 11 to 20 pounds.
• Occasional bending, stooping, kneeling, crouching, reaching.
• Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements.
• Ability to concentrate and maintain accuracy in spite of frequent interruptions.
• Manual dexterity.

Preferred Qualifications :

Background knowledge analysis, assembly, terminal digit filing, and physician s incomplete processing preferred.

Duties :

• Review medical records to identify diagnoses / procedures. Independently organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements.
• Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-10-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.
• Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data including the most complicated encounters / cases.

Assigns Codes :

• Codes all diagnostic and operative information from the medical record using ICD-10-CM, CPT and HCPCS coding classification systems and independently quality checks own work.
• Selects the DRG for each inpatient case.
• Optimizes hospital payment legitimately and ethically by utilizing approved coding guidelines and conventions.
• Reviews DRG discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment.
• Verifies and abstracts, all medical data from the record to complete a data abstract on each hospital encounter. Corrects data as appropriate.
• Ensures that all data abstracted is consistent with guidelines outlined by JCAHO, OSHPD and CMS, regional and local policy.

Completion of Medical Records :

• Interacts with physicians to clarify and accurately document patient diagnostic and procedural information.
• Enters patient information into the computerized inpatient and outpatient medical record databases, ensuring the accuracy and integrity of the medical record abstract data prior to transmitting case to Government Reimbursement for billing.
• Ensures timely record availability by meeting established coding and abstracting productivity standards.
• Independently conducts medical record documentation auditing to monitor physician compliance with regulatory requirements i.

e., Physician Review Project.

Confidentiality / Security of Systems :

• Maintains and complies with policies and procedures for confidentiality of all patient records.
• Demonstrates knowledge of security of systems by not sharing computer logons.

Corporate Compliance Accountability :

Consistently supports the precepts of corporate compliance and Principles of Responsibility by maintaining confidentiality, protecting the assets of the organization, acting with integrity, reporting observed fraud and abuse and complying with applicable state, federal and local laws and program policies and procedures.

Other Duties :

• Answers the telephone promptly and identifies themselves and the department
• Acts as an expert resource person to other coders and personnel in other hospital departments regarding coding questions and issues.
• Other duties as assigned by supervisors.

Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree
• Completion of OB / GYN residency program
• Board certification in Obstetrics and Gynecology
• Current state medical license in good standing
• Strong surgical skills and experience in performing a wide range of OB / GYN procedures
• Excellent communication and interpersonal skills to build rapport with patients and colleagues
• Ability to work in a fast-paced environment while delivering high-quality patient care
• Willingness to work flexible hours, including evenings and weekends
• Commitment to ongoing professional development and staying current with the latest advancements in the field of OB / GYN

Responsibilities

• Provide obstetric and gynecologic care to patients in an outpatient and inpatient setting
• Conduct routine gynecologic exams, including pap smears, breast exams, and pelvic exams
• Diagnose and treat gynecologic disorders and conditions, such as endometriosis, infertility, and menopause
• Perform surgical procedures as needed, including hysterectomies, laparoscopes, and C-sections
• Consult with other healthcare professionals as needed, such as radiologists, oncologists, and urologists
• Educate patients on contraception, family planning, and other reproductive health issues
• Provide prenatal care and manage high-risk pregnancies

Compensation : TBD

Qualifications

• Doctor of Medicine (MD) or Doctor of Osteopathy (DO) degree
• Completion of OB / GYN residency program
• Board certification in Obstetrics and Gynecology
• Current state medical license in good standing
• Strong surgical skills and experience in performing a wide range of OB / GYN procedures
• Excellent communication and interpersonal skills to build rapport with patients and colleagues
• Ability to work in a fast-paced environment while delivering high-quality patient care
• Willingness to work flexible hours, including evenings and weekends
• Commitment to ongoing professional development and staying current with the latest advancements in the field of OB / GYN

Responsibilities

• Provide obstetric and gynecologic care to patients in an outpatient and inpatient setting
• Conduct routine gynecologic exams, including pap smears, breast exams, and pelvic exams
• Diagnose and treat gynecologic disorders and conditions, such as endometriosis, infertility, and menopause
• Perform surgical procedures as needed, including hysterectomies, laparoscopes, and C-sections
• Consult with other healthcare professionals as needed, such as radiologists, oncologists, and urologists
• Educate patients on contraception, family planning, and other reproductive health issues
• Provide prenatal care and manage high-risk pregnancies

Compensation : TBD

Sr. Certified Coder

CA, United States Be the First to Apply

Job Description

Adventist Health is ranked #10 in Becker's list of the largest nonprofit hospital systems in the U.S. We are the largest company headquartered and sixth largest employer in Roseville, California.

Our corporate headquarters have been located at a desirable location on Douglas Boulevard since 1984. To accommodate our growing services, we are creating a new campus that will not only bring our workforce of nearly 900 people together in one location, but also facilitate a deeper connection with our Roseville neighbors and community.

Job Summary :

Reviews patient records to identify the diagnosis and procedure codes performed during the patients stay are valid and in accordance with coding conventions and guidelines.

Applies substantial knowledge of the job and experience to complete a wide range of activities with varying difficulty. Regularly works with sensitive and confidential information, often involving the interpretation of policies and procedures to guide use.

Job Requirements :

Education and Work Experience :

• High School Education / GED or equivalent : Preferred
• Associate’s / Technical Degree or equivalent combination of education / related experience : Preferred
• Two years' coding experience : Preferred

Licenses / Certifications :

• Must possess a current active license in one of the following : Certified Coding Specialist (CCS) or Outpatient Certified Professional Coder (CPC) or Radiation Oncology Certified Coder (ROCC) or Certified Interventional Radiology Cardiovascular Coder (CIRC) or Certified Professional Coder (CPC) or Certified Outpatient Coder(COC) or Certified Coding Specialist-Physician Based(CCS-P) or Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) : Required
• CCS OR CPC OR ROCC OR CIRCC-AAPC OR CCS-Phy OR CC-AAPC OR CCA OR RHIA OR RHIT : Required

Essential Functions :

• Abstracts and assigns diagnosis codes and procedure codes from the patient record to provide information required for billing and reimbursement.
• Audits medical records to ensure proper coding is completed and to ensure compliance with federal and state regulatory agencies.

Applies strategies to improve productivity. Identify trends with tasks and provide feedback to leadership. Identifies and reports possible HAC's or adverse events to Quality Department and HIM.

Provides departmental or enterprise coverage when needed.

• Follows coding guidelines and legal requirements to ensure compliance with federal and state regulatory bodies.
• Collaborates to provide coding feedback and education to departmental leadership regarding completeness and accurateness of documentation and physician coding practices.
• Performs other job-related duties as assigned.

SUMMARY :

Open Door Community Health Centers (ODCHC) relies on billing for services rendered and generated revenue for a significant portion of its operating budget.

ODCHC is committed to proper billing procedures, documentation and review in compliance with federal and state laws and regulations and private payor requirements.

The Coder I Medical, working in collaboration with other Billing and Coding staff and the Coding Manager, is responsible for ensuring that documentation submitted by providers are accurately coded, including a congruence of final diagnoses, professional services, and procedures.

As needed, Coder I will query providers as needed to resolve discrepancies in documentation, apply proper assignment of ICD, CPT and HCPCS codes and / or perform coding addendums to assure timely reimbursement.

ESSENTIAL DUTIES AND RESPONSIBILITIES : These essential responsibilities are performed within the context of collaboration and coordination with ODCHC’s Finance Department.

• Processes encounters submitted to Coder Review Work Queue to ensure congruent coding and documentation.
• Performs comprehensive review of documentation and other records to ensure documentation, signatures, dates, results and other documents are complete and that all services and supplies are included.
• Reviews encounters to ensure ICD diagnosis codes, CPT codes, HCPCS codes are supported and in compliance with payer’s coding and billing requirements or reassigns per documentation.
• Reviews charge sheet to ensure correct code assignments based on internal and / or external documentation.
• Collaborates with other coders and billers to resolve questions and discrepancies and foster quality and team work within the Coding Department;

reports workflow and processing concerns related to PMS and EMR to Coding Manager.

• Attends trainings as assigned and shares information with others as appropriate.
• Mentors others on coding topics and workflows.
• Adherence to ODCHC policies and protocols.
• Other related duties as identified, assigned and required by Coding Manager.

QUALIFICATIONS : The successful candidate will possess experience and skills spanning a variety of areas :

• Have and maintain Medical Coding Certification (COC, CPC or CCS preferred) and meet standards in accordance with Professional Member’s Code of Conduct.
• Computer and computer application skills sufficient to accurately and efficiently use databases, spreadsheets, practice management and electronic health records systems, auditing and word processing software as required.
• Strong interpersonal skills and ability to establish constructive working relationships within the ODCHC Finance Department and with providers and other clinical staff.
• Ability to read, analyze and discuss moderately complex instructions, regulations and documents.
• Ability to prepare routine reports and correspondence.
• At least one year of related experience and / or training in clinical documentation improvement, coding, medical billing and / or auditing.
• Ability to multi-task, work independently, address problems, handle complex situations in a calm manner, and work under time pressures and with diverse colleagues.

SUPERVISORY RESPONSIBILITIES : The Coder I Medical is a non-supervisory position.

SUPERVISION AND SUPPORT : The Coder I Medical reports directly to the Coding Manager. Significant collaboration with other members of the Finance Department is required.

PHYSICAL REQUIREMENTS : This is largely an office-based position. The physical requirements described are representative of those needed to successfully perform the essential duties of the position.

Reasonable accommodation will be made to allow otherwise qualified candidates to perform these functions.

• Speaking and hearing sufficient to communicate effectively by telephone, video or in-person at normal volumes.
• Vision adequate to read documents, computer screens, forms and designs and to differentiate colors as necessary.
• Ability to travel locally.
• Ability to lift and carry boxes and other items weighing up to 25 pounds.
• Ability to sit or stand for extended periods of time.
• Ability to use keyboard and view computer screens for extended periods of time.

Location : Remote or Hybrid or Onsite

Hiring Range $21.23 to $25.46

Position Requirements Wage Range Hiring Range $21.23 to $25.46 EOE Statement Open Door is an equal opportunity employer.

All applicants will be considered for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, medical condition, age, pregnancy, marital status, ancestry, veteran or disability status.