[Hiring] Inpatient Coding Specialist II @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.
• Analyze code assignment and sequence to assure proper DRG assignments.
• Analyze the medical record documentation for complications and comorbidities.
• Analyze medical record documentation for optimum severity of illness and risk of mortality scores.
• 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 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): Ability to write clear, detailed, and comprehensive status reports and documentation.

Core Accountabilities

• Organizational Impact: Executes job responsibilities with an understanding of how output affects 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)

Benefits

• Comprehensive benefits package which may include health, disability, retirement and/or wellness offerings.