Coder II ER (REMOTE)

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Overview

Analyzes physician / provider documentation contained in assigned Emergency Department (ED) and Outpatient Observation health records (electronic, paper or hybrid) to determine the principal diagnosis, secondary diagnoses, principal procedure and secondary procedures. Accesses charge work queues and systems to assign ER and Observation charges if performed by HIM. May also require calculation of Observation hours if performed by HIM.

Utilizes encoder software applications, including all applicable online tools and references in the assignment of ICD-CM diagnosis and procedure codes, and CPT / HCPCS procedure codes and all required modifiers.

Utilizes coding guidelines established by CMS, the American Hospital Association (AHA) Coding Clinic, the American Medical Association (AMA) for CPT codes, the American Health Information Management Association (AHIMA) Standards of Ethical Coding, and Revenue Excellence / Health Ministry (HM) coding procedures and guidelines as applicable.

Responsibilities

• Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions.
• Navigates the patient health record and other computer systems to determine diagnoses, reason for visit, procedures and modifiers to be coded and / or for APC assignment.
• Codes Emergency Department and Outpatient Observation records utilizing encoder software and online tools and references in the assignment of ICD, CPT, and HCPCS codes and modifiers.
• Accesses charge work queues and systems to assign ER and Observation charges and hours, based on medical record documentation, if performed by HIM at a Health Ministry.
• Demonstrates knowledge of current, compliant coder query practices when consulting with physicians, Clinical Documentation Specialists (CDS) or other healthcare providers when additional information is needed for coding and / or to clarify conflicting or ambiguous documentation.
• Communicates effectively with clinical staff, physicians and office staff regarding documentation issues or needs. Communicates with case management concerning Outpatient Observation documentation issues.
• Works with HIM and Patient Business Services (PBS) teams, when needed, to help resolve billing, claims, denials and appeals issues affecting reimbursement.
• Exhibits awareness of health record documentation or other coding ethics concerns. Notifies appropriate leadership for assistance, resolution when appropriate.
• Utilizes EMR communication tools to track missing documentation or Outpatient queries that require follow-up to facilitate coding in a timely fashion.
• Maintains current knowledge of changes in Outpatient coding and reimbursement guidelines and regulations (e.g., new modifiers).
• Consistently meets or exceeds coding quality and productivity standards established by Revenue Excellence / HM.
• Maintains CEUs as appropriate for coding credentials as required by credentialing associations.
• Performs other duties as assigned by leadership.
• Maintains a working knowledge of applicable Federal, State and local laws / regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.

Qualifications

Physical and Mental Requirements and Working Conditions

Compensation

Hourly Pay Range : $24.05 - $36.08

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.

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