Clinical Coder (Onsite)

Job Description

Job Description

Job Title : Clinical Coder

Location : Johnson County Hospital, Tecumseh, Nebraska

Department : Health Information Management

Reports To : HIM Manager

Work Schedule : Working hours are scheduled Monday-Friday. Hours may vary due to workload. Use of overtime is discouraged unless required for patient care needs. Overtime must be approved by immediate supervisor.

Position Summary :

Accountable for conversion of diagnoses and treatment procedures into codes using an international classification of diseases. Requires skill in sequencing of diagnosis / procedures. Ensures that records are coded in an accurate and timely manner for data retrieval, analysis, and claims processing.

Duties & Responsibilities :

• Knowledgeable of all charting and coding requirements, including Acute care, Swingbed, and outpatient services.
• Ensures that records are coded accurately and timely, within four (4) days of discharge, excluding weekends and holidays.
• Reviews medical record thoroughly to ascertain all diagnoses / procedures.
• Abstracts pertinent information from patient records. Assigns ICD-10-CM or HCPCS codes in accordance to the ICD-10-CM / CPT coding principles and the Coding Manual.
• Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
• Contacts responsible provider in a professional, tactful manner.
• Coder's diagnoses and procedures on clinical summary agree with physician's preference.
• Logs diagnoses, procedures, and other abstracting data for registers according to State reporting guidelines.
• Refers to HIM Coding Lead or HIM manager if there is a question regarding the diagnoses / codes.
• Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department manager for resolution.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Demonstrates proficiency in coding and abstracting software / encoder.
• Utilizes coding references available. Reviews coding periodicals within seven (7) days of receipt.
• Analyzes records for completeness and accuracy according to department and hospital policy and procedures for physician and nursing completion.
• Notifies physicians and nursing departments of delinquent or deficient medical records.
• Follows up on incomplete records within one week of notification.
• Runs deficiency analysis reports and other abstracting as requested by HIM manager.
• Performs final qualitative chart analysis to ensure all required documentation has been completed.
• Performs quantitative chart analysis to ensure accuracy of documentation pertinent to encounter, and accurate record preparation for coding.
• Collaborates with Admission staff, Billing staff, Coding Lead and HIM Director as necessary for patient accounts requiring attention for timely and optimal hospital payment.
• Performs quality improvement functions through data collection and documentation review.
• The HIM Coder will understand and demonstrate compliance with HIPAA regulations and will comply with all JCH policies and procedures.
• The HIM Coder will carry out any other responsibilities deemed necessary by the HIM Director.

Qualifications & Skills :

Benefits We Offer :

Why Join Us?

At Johnson County Hospital, we value our team and foster a supportive environment where you can thrive. Join us to make a difference in the lives of our patients and their families.