Clinical Coding Specialist III Full Time, Variable

Facility Cape Fear Valley Medical Center Location Fayetteville, North Carolina Department Health Information Management Job Family Clerical Work Shift Variable (United States of America) Summary Thoroughly reviews the entire medical record to code specifically and accurately those conditions or diagnoses that were treated or affected the patient's plan of care. Verifies that each medical record contains appropriate documentation to justify the selected principal diagnosis to identify comorbid conditions, complications and procedures to use for DRG Assignment. Maintains an accurate case mix index from which administration makes critical management and strategic planning decisions.# Major Job Functions The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time : Codes all diagnoses, treatments, and procedures according to the appropriate classification system for that category of patient encounter, and in accordance with provisions of the Uniform Hospital Discharge Data Set as well as the interpretation of these provisions as issued by the American Hospital Association and American Health Information Management Association and all governmental and private Third Party rules and regulations Performs medical record abstracting of hospital admissions for reimbursement and statistical reporting Concurrently codes LTAC, Rehab and acute care inpatients based on prescribed requirements by payer, using a computerized encoder and DRG grouper Explains to and communicates with physicians regarding the changing of principal diagnoses on the attestation statement, based on lab and other diagnostic findings, when the record may be subjected to PRO review due to vague attestation / documentation

• Assesses the adequacy of documentation to ensure that it supports the principal diagnosis, principal procedure and complications and comorbid conditions that are coded
• Works with Clinical Documentation Specialists and Reimbursement Specialists to identify areas for improvement in physician documentation
• Assesses OCE, NCCI and CCI edits as necessary to apply appropriate modifiers and make appropriate referrals to revenue departments, claim billers, senior coders and other hospital contacts as needed for accurate claim submission
• Analyzes clinical findings to determine appropriate secondary diagnoses for patient severity indices
• Uses independent judgment as to prioritizing charts for retrospective coding based on management of the unbilled accounts report
• Uses good judgment in determining when to delay billing for obtaining additional documentation to support the assignment of a more optimal DRG
• Makes coding supervisor aware of problem issues, negative physician communication and / or other influences that impact effectiveness of job performance
• Other duties as assigned# Minimum Qualifications The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job : ## Education and Formal Training : Bachelor's Degree in Health Information Management or equivalent training and experience RHIA, RHIT, CCS or other equivalent credentials required## Work Experience : 5+ years coding experience required, preferably in a hospital setting 2 years inpatient coding preferred Experience in a Health Information Management in an acute care facility, or with a Peer Review Organization, in Quality Assurance, or Utilization Review preferred## Knowledge, Skills, and Abilities Required : Medical terminology, anatomy and physiology, familiarity with medical record content and an understanding of the Uniform Hospital Discharge Data Set (UHDDS) definitions Knowledge of ICD-CM coding principles under Prospective Payment System Excellent communication skills required
• Understanding that decisions are made with very serious impact affecting hospital reimbursement and PRO review determinations
• High degree of interpretation, analysis, planning, coordination, and organization of information
• Decisions require intense mental effort and consideration of reimbursement ramifications
• Ability to utilize past experience, practices and organization to accomplish goals
• Assigns accurate codes using good judgment in a timely manner within broad guidelines
• Must be flexible and able to concentrate in a busy, noisy, and crowded environment with demands and interruptions 75% of the time## Physical Requirements :
• Near visual acuity required
• Motor coordination required to operate computer
• Work requires commuting between nursing units and Medical Record Department Required Licenses and Certifications RHIA - American Health Information Management AssociationCape Fear Valley Health System is an Equal Opportunity Employer M / F / Disability / Veteran / Sexual Orientation / Gender IdentityFor exceptional healthcare come to Cape Fear Valley Health where caring employees are committed to integrity, patient-centeredness and excellence throughout the entire healthcare process. At Cape Fear Valley Health, our goal is to improve the quality of every life we touch. Our diverse team of doctors, nurses and staff work together to create a better experience for every patient, every time.Cape Fear Valley is a 950-bed, 8-hospital regional health system, the 8th largest in North Carolina, with more than 1 million inpatient and outpatients annually. A private not-for-profit organization with over 7,000 employees and 850 physicians. Our employees and physicians proudly serve a seven-county region of southeastern North Carolina, including Fayetteville, Fort Bragg, Hope Mills, Raeford, Lumberton, Elizabethtown, Clinton, Lillington, Dunn and beyond. Our medical facilities include Cape Fear Valley Medical Center, Highsmith-Rainey Specialty Hospital, Cape Fear Valley Rehabilitation Center, Behavioral Health Care, Bladen County Hospital, Hoke Hospital, Central Harnett Hospital, Betsy Johnson Hospital, as well as more than 60 medical offices and specialty care clinics spread throughout the Cape Fear region.

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