Role Description
Under direct supervision, accurately codes hospital inpatient accounts for the purpose of appropriate reimbursement, research, statistics and compliance to federal and state regulations in accordance with established ICD-10-CM/PCS coding classification systems.
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Serves as a clinical coding subject matter expert, and utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed.
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Analyzes, codes and abstracts complex inpatient cases such as trauma, rehab, neurology, critical care, etc. utilizing the ICD-10-CM and ICD-10-PCS nomenclature to ensure accurate APR-DRG/SOI/ROM and POA assignment.
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Collaborates with other senior coders (and the other coding staff) with sharing coding information and providing coding advice to colleagues regarding complex cases to be coded.
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Monitors assigned work on a daily basis in order to facilitate the billing process within the established timeframes.
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Codes and abstracts records within timeframes established for each patient type.
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Maintains coding quality accuracy rate of 90%.
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Maintains productivity rate of 95%.
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Communicates with various departments within the hospitals regarding billing and registration issues. Refers any problems to management timely, providing clear details.
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Composes appropriate coding queries, works collaboratively with CDI, understands Potentially Preventable Complications (PPC’s)/Maryland Hospital Acquired Conditions (MHAC’s), and Prevention Quality Indicators (PQI’s) and their impact.
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Communicates with the Auditing team to discuss audit findings and works collaboratively in making sure that all accounts are coded appropriately and meet standards of compliance.
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Complies with AHIMA standards of ethical coding and coding compliance guidelines.
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Demonstrates support and compliance with University of Maryland Medical System mission, vision, values statement, goals and objectives and policies.
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Performs other duties or projects such as coding corrections as assigned by the manager.
Qualifications
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High School graduate or equivalent. Formal ICD-10-CM and CPT training Associates or Bachelor’s degree preferred.
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Minimum of three years ICD-10-CM/ICD-10-PCS coding and abstracting experience with at a Level 1 Trauma and Rehab hospital or 4 years of experience with coding inpatient hospital medical records required.
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One of the following required: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Inpatient Coder (CIC).
Knowledge, Skills and Abilities
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Strong analytical and organizational skills.
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Filing systems.
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Ability to prioritize workloads.
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Meet deadlines and work effectively under pressure.
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Excellent customer service skills.
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General office procedures.
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Ability to problem solve and work with minimal supervision.
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Familiar with basic medical terminology.
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Computer experience.
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Typing ability.