Coding Specialist needed in Boston!
This position is responsible for the thorough study of the entire health record for clinical and fiscal data affecting continuity of care, government and third party reimbursement, scientific research, hospital utilization and quality of care patterns, legal and other regulatory requirements. Codes inpatient and/or outpatient diagnoses and procedures and abstracts relevant clinical data. Uses the most recent ICD-9-CM and/or CPT classification, and follows Coding Clinic guidelines and regulatory rules to support the coding decision. Organizes work to assure completion in accordance with departmental policies and procedures.Note: This Coding Specialist description is specific to production coding of inpatient, same day surgery, and observations cases.PRINCIPAL DUTIES AND RESPONSIBILITIES:Reviews the online and/or paper medical record to collect, analyze, assign and sequence codes for diagnoses, procedures, complications, and co-morbidities for each inpatient discharge and/or outpatient cases according to the most recent coding classification system with 95% accuracy.Uses an encoder to verify DRG grouping, and reviews messages to make appropriate DRG determination.Uses online computer to select codes and enters into the computer system. Verifies coding guidelines when appropriate. May consult with physicians through direct contact and written communication on matters pertaining to ICD-9-CM coding conventions, UHDDS definitions, DRG issues, and clinical specificity and documentation requirements.Verifies DRG Assurance assignment from the front-end process, and enters the appropriate reason code when there are differences. 95% accuracy rate or better is expected.Participates in the on-going quality control program that includes the following: Reviews with Quality Specialist any cases that need code changes, and updates codes changes when neededMaintains strict control of chart tracking system within the unit. Follows through with other areas too.Interacts with physicians and other professional staff on documentation issues relating to coded data.Assists other coders in problem-solving documentation and coding issues; may assist Coding Director in training new staff in specific MGH coding guidelines and/or hospital practices.May be assigned to reviews problem cases from billing error list, making corrections and resends information to Billing.Perform interim coding by traveling to the patient floors to analyze and code inpatient medical records in order to maximize case flow.Proactively practices departmental and hospital confidentiality policies and procedures.Completes online productivity report at the end of the shift.Participates in hospital-sponsored workshops and continuing education programs germane to clinical processes and coding issues specific to MGH.Performs other duties as assigned by the Coding Director.QUALIFICATIONS: EDUCATION:Prefer completion of a two to four year program in Health Information Technology or Administration, or Certified Coding Specialist Certificate Program. Prefer college level courses in medical terminology, biology, anatomy and physiology, basic pathology, ICD-9 and CPT coding. Other medical related backgrounds are acceptable provided that Coding Course work has been completed.CERTIFICATION:Accredited, registered or certified in coding by the American Health Information Management Association. Extended experience in coding may substitute for the certification.SKILLS/ ABILITIES/ COMPETENCIES REQUIRED:EXPERIENCE:Minimum of two years experience coding in an acute care hospital environment, teaching hospital experience strongly preferred.Good verbal skills in order to communicate with clinical personnel. In depth and up-to-date knowledge and understanding of anatomy and physiology, medical terminology, and basic pathology.Accurate and quick data entry skills ability to hot-key among multiple computer systems.Encoder experience a plusWORK SAMPLE:Work Sample of ICD-9-CM and/or CPT-4 coding required to assess coding skill level. REQUIRED SKILLS AND ABILITIES:1.Up-to-date and in-depth knowledge of anatomy, physiology, medical science, medical terminology, normal and abnormal laboratory values and generic and brand name drugs for a thorough review of the paper and/or computerized medical record for abstracting and coding accuracy and completion.2.Expert knowledge of ICD-9-CM and CPT coding systems to assign the most precise code possible and to abstract specific clinical data to support hospital-wide case mix activities.3.Judgment to review the record for ambiguities and/or contradictory material; able to discern when another coder and/or physician opinion is needed. 4.Excellent interpersonal skills to interact with physicians and various levels of hospital staff. 5.Writing skill to explain documentation and/or data to physicians and various levels of hospital staff.6.Excellent keyboard skills to access and enter data electronically with 95% accuracy and to meet departmental productivity standards.7.Knowledge of established record order for inpatient and outpatient sections.8.Knowledge of department and hospital policies and procedures related to record tracking, processing and record completion.9.Knowledge of internal organization of Health Information services, policies and procedures related to record tracking and how to refer patients and other hospital personnel to correct department unit. 10.Knowledge of medical staff organization and specific responsibilities for documentation in the medical record. 11. Ability to assist other coders and interact with physicians. WORKING CONDITIONS:Retrieval and filing medical records includes bending accounts for 10% of the time. Sedentary work including use of keyboard accounts for 90% of the time. Keyboard use is not constant, but it is a major portion of the job.