Health Information Management Coder I - Providence Hospital

Overview

USA Health is Transforming Medicine along the Gulf Coast to care for the unique needs of our community. 

USA Health is changing how medical care, education and research impact the health of people who live in Mobile and the surrounding area. Our team of doctors, advanced care providers, nurses, therapists and researchers provide the region's most advanced medicine at multiple facilities, campuses, clinics and classrooms. We offer patients convenient access to innovative treatments and advancements that improve the health and overall wellbeing of our community.

Responsibilities

Abides by and enforces all compliance requirements and policies and performs these responsibilities in an ethical manner consistent with the organization’s values; adheres to hospital policies including confidentiality; utilizes proper body mechanics when moving equipment/supplies/records that are necessary to perform essential functions; assists with orientation of new employees as assigned; maintains clean work environment; utilizes and accesses the Hospital Information System (Cerner), 3M, EDM, Soarian Clinicals, CribNotes, OB TraceVue, and Command Health; informs supervisor when supplies are low; reviews patients’ entire medical records and assigns appropriate codes using ICD-10-CM/ICD-10-PCS/ICD-9-CM/CPT/3M coding systems; codes records within five days of discharge; codes a minimum of 2 Medicare Inpatient or 3 non-Medicare Inpatient or 6 Newborn Inpatient or 6 Obstetrical Inpatient or 5 Outpatient Surgery/Observation or 12 ER/OB screening records per hour; records the principal diagnosis and procedure, as well as the sequence of all other diagnoses and procedures according to the uniform discharge data system;identifies complications and comorbidities in order to assign the most appropriate DRG/APR-DRG; develops and assigns physician coding queries when documentation clarification is needed in order to assign the mostaccurate and appropriate code; assists physicians, Business Office and other medical record requestors by pulling charts, answering questions regarding chart completion requirements and performing follow-up; reviews and actively works on the Missing Elements List weekly; informs supervisor of outstanding records not coded within five days of discharge; communicates with the medical staff and other healthcare providers on proper documentation of severity of illness and intensity of service to ensure optimal reimbursement; communicates and uses appropriate customer relations skills with physicians, patients, families, healthcare team and staff in person and via telephone; responds to overhead pages; informs/relays information to incoming shifts regarding any unfinished requests/duties; maintains accurate and complete records; identifies and posts all forms and reports in the correct chart order; completes the daily departmental routing slip; maintains accurate logbooks; updates Cerner and EDM information as needed; removes specified forms/reports from the medical record (as appropriate) for reviewers/requestors; verifies that information sent via fax machine is done so without error by reviewing fax log; completes all mandatory unit, educational and hospital requirements; utilizes cost effective practices in performing all aspects of the job; adheres to current Infection Control and Safety Standards; participates on committees as assigned; participates in Performance Improvement activities as assigned; accesses and accurately maintains paper and electronic medical records; regular and prompt attendance; ability to work schedule as defined and overtime as required; related duties as required.

Qualifications

Associate’s degree in a health information technology program accredited by the Commission on Accreditation for Health Informatics and Information Management Education (AHIME) and current certification with the American Health Information Management Association as a Registered Health Information Technician (RHIT).