The Inpatient Coder I is a regional position and the primary function of this position is performing coding and abstracting of inpatient and ambulatory records using the ICD-10-CM classification system and MS-DRG expertise. Inpatient Coder I responsibilities will cover all inpatient encounters and will focus on observation cases. Through the assignment of appropriate ICD-10-CM codes, the Inpatient Coder I will play a critical role in Dignity Health's billing, internal and external reporting, research, and regulatory compliance efforts. The position works in a cooperative team environment to provide value to customers both internal and external to Dignity Health.
Nature and Scope:
This position reports to the Coding Supervisor.
Primary Responsibilities: developing and maintaining good communications and working relationships with the medical staff, administrative staff, outside agencies and with other departments.
Duty to Support the Mission and Philosophy of Dignity Health:
This position upholds the best interests of Dignity Health by adhering to the highest standards of ethical and moral conduct and by committing to the values of Dignity Health's mission and philosophy.
- Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system for complex inpatient encounters utilizing a computer assisted coding system.
- Spend a minimum of 50% of time on observation encounters.
- Review provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures.
- Utilize technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD-10-CM diagnoses and procedures.
- Ensure accurate coding by clarifying diagnosis and procedural information through a query process.
- Assign present on admission (POA) value for inpatient diagnoses.
- Extract required information from source documentation and enter into encoder and abstracting system.
- Identifies non-payment conditions (HAC) and when required, report through established procedures.
- Reviews documentation to verify and, when necessary, correct the patient disposition upon discharge.
- Prioritize work to ensure timeframe of medical record coding meets regulatory requirements.
- Serve as a resource for coding related questions to other Dignity Health employees as appropriate.
- Meet performance and quality standards at the Inpatient Coder I level.
- Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
- High School Diploma or equivalent required.
- CCS, CCS-P, RHIT, or RHIA preferred.
- One year of relevant coding and abstracting experience or equivalent combination of education and experience required.
- Prior coding classes required. Applicants must have completed one of the following:
- Anatomy / Physiology, Medical Terminology and ICD-10 and CPT coding courses conforming to American Hospital Association, American Medical Association, or CMS standards.
- An AAPC or AHIMA accredited coding certification program.
- Performance Measures
- Exceeds Dignity Health's coding accuracy and productivity standards at the Inpatient Coder I level
- Consideration for movement to Inpatient Coder II includes demonstrated higher level productivity and quality as well as an entry level familiarity of inpatient coding.
Knowledge, Skills and Abilities:
- Analytical / Critical thinking
- Problem Solving
- Knowledge and application of ICD-10-CM, HCPCS and CPT-4 classification High ethical standards.
- Excellent written and verbal communication skills, including the ability to present ideas and concepts effectively across organizational levels.
- Knowledge of information privacy laws, access, release of information, and release control technologies.
- Knowledge of hospital protocols and procedures.
- Working knowledge of functional relationships between departments within a healthcare or similar environment.
- Knowledge of JCAHO, HIPAA, HCFA, Title 22, security principles, guidelines, and standard healthcare practices.
- Demonstrated competence with personal computers, networks, and Microsoft Office.
Dignity Health, one of the nation's largest health care systems, is a 21-state network of 9,000 physicians, 59,000 employees, and more than 400 care centers, including hospitals, urgent and occupational care, imaging centers, home health, and primary care clinics. Headquartered in San Francisco, Dignity Health is dedicated to providing compassionate, high-quality, and affordable patient-centered care with special attention to the poor and underserved. In FY15, Dignity Health provided $1.7 billion in charitable care and services. For more information, please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook.
Dignity Health is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status. For more information about your EEO rights as an applicant, please click here.