Job Description:
Summary:
Under the basic guidance of the Health Information Coding Manager, examines the inpatient medical record to appoint suitable codes in accordance with the ICD-10- CM/PCS Official Guidelines for Coding and Reporting. Figures out proper MS DRG/APR DRG task for ideal category and precise and certified medical reporting. Determines and suggests doctor inquiries when documents in the chart is insufficient, uncertain or uncertain. Maintains and satisfies HIS quality and performance requirements.
Responsibilities:
Enters into a composed Telecommuting Agreement with department management. The staff member accepts be available by telephone/e-mail within a sensible period throughout the concurred upon work schedule, and to officially keep prompt and precise work and pause records and to send such work hours weekly to department management in accordance with Lifespan’s system broad composed “Telecommuting” policy.
Reads and understands the inpatient medical record determining all dealt with medical diagnoses and treatments reporting the appropriate code( s) sticking to guidelines stated in “Official Coding Guidelines.” Carries out coding recognition on codes computer-assisted and auto-suggested codes from 3M.
Understands scientific paperwork to acknowledge when an inquiry to the doctor is needed.
Working understanding of medical paperwork such as laboratory results recognizing breathing failure, unchecked diabetes etc., and capability to carry out web searches when fuller understanding is needed to even more comprehend illness procedures & medications to deal with.
Codes uncomplicated inpatient medical records such as seen in neighborhood medical facilities omitting Level 1 injury cases and complicated surgical cases.
Reviews web videos for complete understanding of treatments for coding precision.
Ability to browse the electronic medical record. Guarantees the medical record paperwork supports the codes picked for the primary medical diagnosis, secondary medical diagnoses, problems, co-morbid conditions, treatments and discharge personality. Abides by the “Standards of Ethical Coding” as stated by the American Health Information Management Association. Gets in coded/abstracted details and/or confirms codes into the 3M DRG grouper designating using computer-assisted coding tools. Designates precise MS-DRG or APR-DRG through usage of the medical studying functions evaluated in compliance with medical record paperwork. Includes Present On Admission (POA) sign to medical diagnoses. Determines Hospital Acquired Condition and Patient Safety Indicator codes and forwards to designee. Chooses the doctor carrying out treatments guaranteeing precision in the medical facility’s billing system. Functions carefully with Clinical Documentation Specialist for extra medical evaluation Responds prompt to coding validator coding suggestions. Focuses on high paying records to be finished the day got. Carries out concurrent coding for internal clients needing interim billing. Constantly fulfills coding performance, quality and precision requirements.
May be needed to code rehab records following the recognized procedure.
Consistently satisfies recognized efficiency requirements and precision requirements.
Follows-up on all costs holds to guarantee prompt billing and compensation. Serve as a resource to doctors and other personnel on coding principals and DRG tasks and/or outpatient coding problems.
Refers coding, billing and system concerns to the coding supervisor or coding validator. Seeks supervisory support just after tiring own resources by referencing suitable coding publications and handbooks. Assists other coders with assistance answering concerns and supplying assistance to entry-level coders.
Keeps abreast of coding standards and repayment reporting requirements. Maintains credential.
Maintains health info privacy by sticking to recognized organizational and department policies and treatments.
Performs associated clerical and other tasks as designated.
Other info:
BASIC KNOWLEDGE:
Associate degree needed; health infotech chosen. (ideally with RHIT or RHIA) and AHIMA CCS Certified Coding Specialist credential. If associate degree is not in health infotech, effective conclusion of an inpatient coding accreditation program certified by AHIMA. or the AAPC credential CIC, Certified Inpatient coder. Great writing abilities to prepare certified doctor questions. Computer system literate; efficient in looking into web sites to clarify illness or treatments. Capability to browse the client electronic medical record to gain access to and acknowledge suitable information relevant to coding procedure.
EXPERIENCE:
Three to 5 years inpatient coding experience in a mentor or severe care healthcare facility needed with shown capability to comprehend the scientific material of a health record. Trained in medical terms, anatomy and physiology. Capability to acknowledge and comprehend medical documents important for coding. Excellent writing abilities to prepare certified doctor inquiries. Computer system literate; efficient in research study web sites to clarify illness or treatments. Capability to browse the client electronic medical record to gain access to and acknowledge suitable information relevant to coding procedure.
WORKING CONDITIONS:
Reads electronic medical records for the whole workday double computer system screens. Capability to sit for extended periods, raise a minimum of 25 pounds, bend, stoop, stretch, usage step-stools to submit records. Capability to work under demanding conditions to preserve balance dues days attaining performance and precision.
INDEPENDENT ACTION:
Performs individually within the department’s policies and practices. Refers particular complex issues to the manager when information of the department policies and treatments are needed.
SUPERVISORY RESPONSIBILITY:
None.
Lifespan is an Equal Opportunity/ Affirmative Action company. All certified candidates will get factor to consider for work without regard to race, color, religious beliefs, sex, nationwide origin, age, ethnic culture, sexual preference, origins, genes, gender identity or expression, impairment, secured veteran or marital status. Life expectancy is a VEVRAA Federal Contractor.
Location: Corporate Headquarters, USA: RI: Providence
Work Type: Full Time
Shift: Shift 4
Union: Non-Union.
Life-span Health System.
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