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Coder III | Health Information Management | Full time

Rapid City, SD Full time 21_2161.1

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Job Category

Revenue Cycle

Department

RCH Health Information Management

Scheduled Weekly Hours

40

Shift

Employee Type

Regular

Job Summary

Accurately and efficiently codes and abstracts comprehensive acute care inpatient, rehabilitation inpatient, outpatient surgery, swing bed, long term care, ancillary services and short stay observation patient records according to official coding guidelines for accurate coding and benchmarks for productivity. Evaluates and assigns accurate DRG, PAI, and APC assignment. The position responsibilities include 95% comprehensive assignment of inpatient ICD 9 diagnosis, DRG, Ambulatory Patient Classification assignments, comprehensive review of the entire inpatient, observation, or ambulatory record, accurate documentation capture for accurate and compliant code and procedure assignment. Responsibility includes occasional backup for diagnostic outpatients.

Job Description

Essential Functions:

  • Analyzes, audits, and abstracts clinical record information for all patient encounters according to the established parameters. Ensures the accuracy, completeness, and propriety of medical information both text based and encoded in all patient care settings.
  • Assists with keeping discharged unbilled accounts within limits as specified by CEO.
  • Assigns and sequences diagnosis and procedure codes for all patient encounters utilizing applicable ICD-9, CPT-4 and HCPC coding systems. Keeps current with changes in statutory regulations to ensure coding compliance.
  • Assists the Office Supervisor and Directors with miscellaneous office support tasks upon request.
  • Assures confidentiality of Medical Records in accordance with hospital policy.
  • Completes facility charges for outpatient services as assigned.
  • Discharge Analysis Quality: Analyzes discharge records for completeness and accuracy of documentation and prepares deficiency lists for physicians by entering the needed items into the incomplete record system. a) SO/OPS Discharge Analysis Quality, b) Inpatient Discharge Analysis Quality.
  • Educates, and communicates with Providers and Hospital workforce in the area of clinical documentation, DRG assignment and coding guidelines.
  • Inpatient Coding and DRG Quality: Accurately selects appropriate diagnosis and procedure codes for all inpatient medical records in accordance with established guidelines, remaining under a 5% error ratio. Appropriately assigns correct DRG.
  • Provides technical assistance for authorized data retrieval from the coding database. Serves as a resource for others with questions, inquiries concerning coding applications, compliance, and data interpretation.
  • All other duties as assigned.

Additional Requirements

Preferred:
Experience - 3+ years of Hospital Coding Experience
Education - Associates degree in Health Information Management
Certifications - Certified Coding Specialist (CCS) - American Health Information Management Association (AHIMA); Certified Professional Coder - Apprentice (CPC-A) - American Academy of Professional Coders (AAPC); Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA); Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA)

Physical Requirements:
Sedentary work - Exerting up to 10 pounds of force occasionally and/or negligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time.

10 Monument Health Rapid City Hospital, Inc.

Make a differenceEvery day.

Monument Health is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, or protected Veteran status.

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