Senior Coder Complex - Inpatient

POSITION SUMMARY

This position provides coding and abstracting for high tiered complexity range of acute care services at all Banner hospitals.

Reviews diagnosis and diagnostic information and codes and abstracts diagnoses and / or procedures on inpatient records using ICD CM and PCS coding classification systems.

Completes MS-DRG and APR-DRG assignments on inpatient records as appropriate. Ensures ethical and accurate coding in accordance with all regulatory requirements and AHIMA Standards of Ethical Coding.

Acts as subject-matter expert regarding experimental and newly developed procedural and diagnostic inpatient coding.This includes highest level of complexity of accounts encountered in Banner’s Academic, Trauma and high acuity facilities.

Will serve as a role model for less experienced acute care coding Inpatient team members.

CORE FUNCTIONS

1. Analyzes medical information from medical records. Accurately codes diagnostic and procedural information in accordance with national coding guidelines and appropriate reimbursement requirements.

Consults with medical providers to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes.

Provides timely and accurate coding in accordance to department specific productivity and quality standards thorough assignment of ICD CM and PCS codes, MS-DRGs, APR-DRGs and POAs for highest level of complexity of Inpatient accounts encountered in Banner’s Academic, Trauma and high acuity facilities.

2. Abstracts clinical diagnoses, procedure codes and documents other pertinent information obtained from the patient encounter.

Seeks out missing information and creates complete records, including items such as disease and procedure codes, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons and anesthesiologists.

Refers inconsistent patient treatment information or documentation to coding support tech, coding quality analyst or coding manager for clarification / additional information for accurate code assignment.

3. Provides coding quality assurance for medical records. For all assigned records and / or areas assures compliance with coding rules and regulations according to regulatory agencies for state Medicaid plans, Center for Medicare Services (CMS), Office of the Inspector General (OIG) and the Health Care Financing Administration (HCFA), as well as company and applicable professional standards.

Ability to address related and complex matters independently with regard to interpretation of coding guidelines.

4. Acts as a knowledge resource for internal and external customers. Acts as subject-matter expert regarding experimental and newly developed procedural and diagnostic inpatient coding.

Will provide mentorship to less experienced or otherwise identified staff members.Will collaborate with Acute Care Coding Leaders and Education team in identifying need for new and / or ongoing training for ACC team.

5. Works under general supervision using specialized expertise in the subject matter. Works within a set of defined rules.

Ability to address related and complex matters independently with regard to interpretation of coding guidelines prior to referral to senior manager, educator or Coding Quality Analyst.

MINIMUM QUALIFICATIONS

High school diploma / GED or equivalent working knowledge and specialized formal training in medical record keeping principles and practices, anatomy, physiology, pathology, medical terminology, standard nomenclature, and classification of diagnoses and operations, or an Associate’s degree in a health care field.

Requires Certified Coding Specialist (CCS) or Certified Outpatient Coder (COC) or Certified Professional Coder (CPC) or Registered Health Information Technologist (RHIT) or Registered Health Information Administration (RHIA) or other appropriate coding certification in an active status with the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC).

Must demonstrate a level of knowledge and understanding of ICD CM and PCS coding principles as recommended by the American Health Information Management Association coding competencies.

Requires five or more years of inpatient coding experience in Acute Care inpatient facility or healthcare system.

Must be able to work effectively and efficiently in a remote setting, utilizing common office software and coding software and abstracting systems.

PREFERRED QUALIFICATIONS

Associates degree in a job-related field or experience equivalent to same.

Previous experience in large, multi-system healthcare organization.

Additional related education and / or experience preferred.

EOE / Female / Minority / Disability / Veterans

Our organization supports a drug-free work environment.

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