[Hiring] Inpatient Coding Specialist @Vanderbilt University Medical Center

Role Description

Reviews documentation in the electronic medical record and assigns and sequences ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes, in accordance with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and in compliance with ICD-10 Official Coding Guidelines and other regulatory requirements. Responsible for coding mortality and high dollar (over $400k) complex discharges and will draft physician queries, to clarify documentation for optimal coding and quality reporting.

Key Responsibilities

• Review, analyze and interpret the entire electronic medical record for the current admission to identify all diagnoses and procedures documented during the admission.
• Determine and assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes.
• Identify cases with clinical indicators that may require provider documentation clarification and/or specificity to accurately assign codes.
• Collaborate with CDIS team as part of the clinical documentation validation and physician query workflows.
• Analyze code assignment and sequence to assure proper DRG assignments.
• Analyze the medical record documentation for complications and comorbidities.
• Confirm Admission-Discharge-Transfer (ADT) information and correct when necessary.

Technical Capabilities

• COMPLIANCE (Advanced): Understanding the rules, regulations, sanctions and other statutory requirements.
• MEDICAL TERMINOLOGY & DOCUMENTATION (Expert): The ability to comprehend medical terminology and documentation.
• CRITICAL THINKING (Advanced): The objective analysis and evaluation of an issue in order to form a judgment.
• MEDICAL CODING (Expert): The transformation of healthcare diagnosis, procedures, medical services, and equipment into universal medical alphanumeric codes.
• WRITTEN COMMUNICATION (Advanced): Demonstrates the ability to write clear, detailed, and comprehensive status reports, memos and documentation.

Core Accountabilities

• Organizational Impact: Executes job responsibilities with the understanding of how output would affect and impact other areas.
• Problem Solving/ Complexity of work: Analyzes moderately complex problems using technical experience and judgment.
• Breadth of Knowledge: Has expanded knowledge gained through experience within a professional area.
• Team Interaction: Provides informal guidance and support to team members.

Core Capabilities

• Supporting Colleagues: Develops self and others; builds and maintains relationships; communicates effectively.
• Delivering Excellent Services: Serves others with compassion; solves complex problems; offers meaningful advice and support.
• Ensuring High Quality: Performs excellent work; ensures continuous improvement; fulfills safety and regulatory requirements.
• Managing Resources Effectively: Demonstrates accountability; stewards organizational resources; makes data-driven decisions.
• Fostering Innovation: Generates new ideas; applies technology; adapts to change.

Qualifications

• High School Diploma or GED (Required)
• 5 years of relevant work experience

Certifications

• Certified Coding Associate - American Health Information Management Association (AHIMA)
• Certified Coding Specialist - American Health Information Management Association (AHIMA)
• Certified Coding Specialist - Physician - American Health Information Management Association (AHIMA)
• Certified Outpatient Coder - American Academy of Professional Coders
• Certified Professional Coder - Outpatient - American Academy of Professional Coders
• Registered Health Information Administrator (RHIA) - American Health Information Management Association (AHIMA)
• Registered Health Information Technician (RHIT) - American Health Information Management Association (AHIMA)

Company Description

Vanderbilt Health is committed to fostering an environment where everyone has the chance to thrive and is committed to the principles of equal opportunity. EOE/Vets/Disabled.