Clinical Coder (40 hours/week)

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Summary

Job Description

POSITION SUMMARY: : Codes and abstracts information from inpatient and outpatient records by careful analysis and adherence to official coding guidelines assuring appropriate reimbursement, compliance with regulations, and accuracy for clinical care analysis and provider profiling.

ESSENTIAL FUNCTIONS: Qualified individuals must have the ability (with or without reasonable accommodation) to perform the following duties:

• Demonstrates commitment to the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).  Assigns codes based upon clinical coding guidelines.

• Assigns ICD-10-CM diagnostic, procedure codes with appropriate present on admission indicators to inpatient records, based upon the practitioner clinical documentation.  Determines appropriate MS-Diagnostic Related Group (DRG) based upon diagnoses and procedure codes assigned. 

• Assigns ICD-10-CM diagnostic and CPT procedure codes and modifiers to outpatient accounts.  

• Applies drug administration charges to outpatient accounts based on the clinical documentation and guidelines.

• Applies observation hour charges to observation accounts based on the clinical documentation and guidelines.

• Reviews and appropriately applies modifiers to the NCCI (National Correct Code Initiative) and OCE (Outpatient Code Edits).    

• Abstracts required clinical and demographic data from inpatient and outpatient records.

• Participates in data quality peer review process, reviewing records according to established procedure.

SECONDARY FUNCTIONS: The following duties are considered secondary to the primary duties listed above:

• Assists Patient Financial Services and physician offices with coding—related issues.

• Completes a productivity record on a daily basis and submits to Clinical Coding Coordinator monthly.

• Assists with appropriate capture of inpatient case mix.

JOB REQUIREMENTS

MINIMUM REQUIRED QUALIFICATIONS:

•  High school diploma or equivalent (GED).
• Formal education in ICD-10-CM/PCS and CPT-4 coding, medical terminology, anatomy and physiology.
• Certification as a Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician (CCS-P) through AHIMA (American Health Information Association), or certified by AAPC (American Association Professional Coders) with certification as a Certified Professional Coder (CPC), or Certified Professional Coder-Hospital Outpatient (COC).  If not certified, coding certification is required within three (3) years of employment. 
• Experience in ICD-10-CM/PCS coding/MS-DRG assignment (this may include student work experience) Experience in CPT-4 coding (this may include student work experience)

PREFERRED QUALIFICATIONS:

• Some experience with encoding software.

COGNITIVE REQUIREMENTS

ATTENTION/CONCENTRATION – The following level of ability is essential for the jobholder to focus on certain aspects of current experience and reject others:

• The position requires the ability to attend to a specific stimulus without being distracted by extraneous environmental stimuli.  The individual must be able to attend to environmental detail with the ability to separate essential from non-essential or irrelevant stimuli.  The attention skills required are generally considered to be automatic - - passive, but focused with an intact capacity for select perception.

NEW LEARNING AND MEMORY – The following level of ability is essential for the jobholder to learn and retain material:

• Job demands are only moderately routine and predictable.  Minor changes may occur which require the individual to be able to understand and carry out detailed but uninvolved instructions.

PROBLEM SOLVING, REASONING AND CREATIVE THINKING – The following level of ability that is essential for the jobholder to think (in order to solve a problem) by combining two or more elements from past experience or imaginative thought:

• The position required much autonomy of thought and problem solving.  The individual must be able to apply principles of logical or scientific thinking to define problems.  The individual must be able to think abstractly, which is manifested in the ability to form concepts, use categories, generalize from single instances, apply procedural rules and general principles, and be aware of subtle or intrinsic aspects of a problem.  The development of hypothesis and potential solutions to problems involves careful interpretation, analysis and diagnosis.  The individual must be able to collect data, establish facts, and draw valid conclusions.  The individual must be able to think creatively with a degree of inventiveness, experimentation and intuition.  They must be able to deal with a variety of concrete and abstract variables.

TEMPERAMENTS:  The following are essential requirements of the position in relation to job-worker situations.  These items describe how a worker must adapt, adjust, conform or act:

Repetitive work: Ability to continuously perform the same type of work for extended periods of time, according to set procedures, sequence or pace.

Working within tolerances, set limits or standards: Ability to adapt to situations requiring the precise attainment of set limits, tolerances, or standards; to be precise, thorough, exacting, or meticulous in regard to material worked; or in activities such as numerical determinations, record preparation, or inspecting.

Communication:  Ability to exchange information with others clearly and concisely; to present ideas, facts and technical information.

Planning and control: Ability to identify task requirements and monitor progress toward accomplishment.

Interpersonal relations: Ability to maintain relationships that facilitate task accomplishment; to cooperate and resolve conflicts; to recognize needs and be sensitive of others.

EQUIPMENT USAGE REQUIREMENTS

Equipment/Tools: computer, printer, telephone, office supplies

Software: 3M encoder, MS-DRG grouper, EPIC coding and abstracting system, Clintegris

PHYSICAL REQUIREMENTS

Rarely 0-10%; Occasionally 11-35%; Frequently 36-70%; Continuously 71-100%

Body Position/Movement:

• Sit: Continuously
• Stand: Rarely
• Walk: Rarely
• Bend: Rarely
• Push: Rarely
• Pull: Rarely
• Kneel/Squat: Rarely
• Reach: Rarely
• Twist: Rarely
• Balance: Rarely
• Climb: Rarely

Lifting: Degree of physical exertion is:

Light, exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently or constantly to move objects.

Sensory Abilities specifically required:

• Vision
• Hearing

PHYSICAL ENVIRONMENT

WORKING CONDITIONS: Exposure to hazardous conditions/ materials is negligible.                                   

Disclaimer: This job description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job.  It is intended to be a reflection of those principal job elements essential for recruitment and selection, for making fair job evaluations, and for establishing performance standards.  The percentages of time spent performing job duties are estimates, and should not be considered absolute.  The incumbent shall perform all other functions and/or be cross-trained as shall be determined at the sole discretion of management, who has the right to amend, modify, or terminate this job in part or in whole.  Incumbent must be able to perform all job functions safely.

Disclaimer

MILL Full Time Posted on 11/18/2024