Under indirect supervision, responsible for accurate coding of all inpatient, and/or outpatient services diagnoses, procedures and conditions, working from the appropriate documentation in the medical record.
DEPARTMENT: Health Information Management - Fremont SCHEDULE: Full-Time Regular, 40 hours per week, Day shift. Monday through Friday: 8:30am to 5:00pm. EDUCATION: Must have High School Diploma or GED. Completion of classes in Medical Terminology, anatomy and physiology, ICD-9-CM and CPT coding conventions and disease process from an Accredited Program is required. LICENSE/CERTIFICATION: This position requires certification Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA). JOB SUMMARY: Under indirect supervision, responsible for accurate coding of all inpatient, and/or outpatient services diagnoses, procedures and conditions, working from the appropriate documentation in the medical record. Classification system includes ICD-9-CM, CPT and HCPCS as well as other specialty systems as required by diagnostic category. All work is carried out in the accordance with the rules, regulations and coding conventions of the American Hospital Association (Coding Clinic), ICD-9, CMS, OSHPD and Kaiser Coding Guidelines. QUALIFICATIONS: . Must have at least five (5) years of continuous inpatient hospital coding/abstracting experience within the last seven (7) years. . Demonstrated ability to understand the clinical content of a health record including the most complicated records. . Must also be able to communicate with physicians in order to clarify diagnoses/procedures and sequencing of diagnoses. . Must be able to meet quantity and quality standards established for Coder II´s. . Demonstrated ability to utilize principles and techniques of health record/data quality assurance and abstracting. . Ability to manage coding backlogs and maintain policies and procedures related to the case mix index, accounts receivable and accumulation, processing and currency of data. . Basic PC Skills . Must pass Kaiser Coding Test at 75%. . Must maintain a minimum of ten (10) CE units annually. Must maintain current coding credential. . Will abide by the AHIMA coding code of ethics. . Must be able to work in a Labor/Management Partnership. Preferred Qualifications: Background knowledge analysis, assembly, terminal digit filing, and physician´s incomplete processing preferred. Knowledge of professional services billing processes preferred. Physical and Mental Demands: . Ability to sit of long periods of time . Ability to lift, push or pull 11-20 pounds. . Occasional bending, stooping, kneeling, crouching, reaching. . Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements. . Ability to concentrate and maintain accuracy in spite of the frequent interruptions. . Manual dexterity. SKILLS TESTING: Coder II Test with passing rate of 75%, Medical terminology, Basic PC skills, Excel and Word, 35 WPM DUTIES: . Review medical records to identify diagnoses/procedures. . In concert with HIM Department supervisors and managers, organizes and prioritizes all work to ensure that records are coded in timeframes that will assure compliance with regulatory requirements. . Demonstrates an in-depth expert level knowledge of all procedures concerning the sequencing of diagnoses, procedures as outlined in but not limited to ICD-9-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems. . Demonstrates knowledge of anatomy and physiology to interpret general medical classifications for coding discharge data including the most complicated, involved encounters/cases. Other duties: . Answer the telephones promptly and identifies themselves and the department. . Acts as a resource person to other hospital departments regarding coding questions and issues. . Other duties as assigned by supervisors. Assign Codes: . Codes accurately and completely all diagnostic and operative information from the medical record using ICD-9-CM, CPT, and HCPCS coding classification systems. . Accurately selects the DRG for each inpatient case. . Optimizes hospital payment legitimately and ethically, based on approved coding guidelines and conventions and practices which meet complaisance requirements. . Review DRG discrepancies from the fiscal intermediary to ensure the appropriate per case DRG assignment. . Verifies and abstracts all medical data from the record to complete a data abstract on each hospital encounter. Corrects data as appropriate. . Ensure that all data abstracted is consistent with guidelines outlined by JCAHO, OSHPD, and CMS, regional and local policy. Medical Record Peer Review: . On a regular, scheduled basis performs ongoing peer review of select inpatient and outpatient cases to ensure correct reimbursement for all hospital coding compliance. . Participates in quality improvement peer review for coding, abstracting, and DRG/APC assignments performed within the HIM department. . In concert with HIM department supervisors and managers, identifies department performance/quality improvement opportunities. Based on assessed and/or identified needs, conducts training and in-service education for assigned staff and serves as an expert on ICD-9-CM/CPT/HCPCS and DRG/APC assignments, issues and projects. Completion of Medical Records: . Interacts with physicians to clarify and accurately document patient diagnostic and procedural information. . Enter patient information into the computerized inpatient and outpatient medical record databases, ensuring the accuracy and integrity of the medical record abstract data prior to transmitting case. . Ensure timely record availability by meeting established coding, abstracting and peer review productivity and quality standards specific to Coder IIIs. . Participates in medical record documentation review to monitor physician compliance with regulatory requirements i.e. Physician Review Project. In concert with appropriate managers, may provide physician review and education based on review findings. Confidentiality/Security of Systems: . Maintains and complies with policies and procedures for confidentiality of all patient records. . Demonstrates knowledge of security of systems by not sharing computer logons. Consistently supports compliance and the Principles of Responsibility (Kaiser Permanente´s Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanente´s policies and procedures. PLEASE NOTE: - Kaiser Permanente is an AA/EEO employer-