Codes and abstracts inpatient medical records of all types and following a rigorous review of the clinical documentation, abstracts and assigns appropriate ICD-10-CM/PCS code sets and assigns the correct APR DRG into the hospital information system. May also code other work types as assigned by Coding Manager.
Primary Duties / Competencies Weight Accuracy & Quality
Demonstrates a sustained >/= 95% accuracy in APR DRG assignment into the hospital Information System as reported through independently validated external Coding QA Audit results. Establishes a track record of producing consistently accurate work that demonstrates attention to detail and reflects well on the organization. Demonstrates personal commitment to high quality work and encourages others to have similar standards.
Communicates effectively and appropriately. Uses good judgment as to what to communicate to whom as well as the best way to get that accomplished. Speaks in a clear and credible manner, selecting the right tone for the situation and audience. Listens to others and allows them to make their point.
Seeks/collects and synthesizes information from a variety of stakeholders and sources using various data collection techniques. Clearly validates accuracy of coded data and resolves any inconsistencies through timely and succinctly written Physician Queries. Seeks additional input from Team members as needed to resolve variances and data gaps. Demonstrates ability to objectively analyze data, and to determine if the data supports the intended goals or desired outcomes
Possesses sufficient job skills and knowledge to perform the job in a competent manner. Is able to demonstrate skills and knowledge in day-to-day situations. Demonstrates technical competencies, standards, and skills; and the ability to apply in day-to-day situations.
Time Management & Productivity
Demonstrates a sustained Productivity Outcome as established by the hospital HIM Director and Coding Manager. Prioritizes tasks and manages time to ensure that deadlines are met. Prevents or manages interruptions until the highest priority tasks are accomplished. Consistently plans time to ensure adherence to timelines. Proactively renegotiates timeline when necessary, ensuring consensus among all stakeholders.
Meets or exceeds productivity standards that have been established for his/her organizational level or position. Has successfully combined skills, ability and effort level to ensure that expectations related to results/output are achieved.
- Maintains expected level of attendance and punctuality
- Completes annual education requirements on–time and demonstrates ongoing focus on personal
- Adheres to all policies and procedures
- Demonstrates regard to (Alliance) core values
- Other duties as assigned by supervisor
Minimum Knowledge, Skills, & Abilities
High School Diploma or GED required. Completion of a Coding Certificate Program is required, completion of college level classes in Anatomy, Pathophysiology and Pharmacology.
At least one of the following: CCS (Certified Coding Specialist), RHIA or RHIT credential is required
In addition, 5 years hospital coding experience which includes coding of inpatient records or a combination of inpatient and outpatient records using both ICD-10-CM and CPT-4 is preferred. Demonstration of skills through completion of a hospital administered advanced coding test with a satisfactory score.
PC experience; ability to use computer terminals for prolonged periods to enter data.
Ability to work under time and productivity constraints.
Ability to work with frequent distractions/interruptions.
Ability to read records and handwriting of differing levels of legibility for prolonged periods.
Attention to detail.
Good organizational skills.
Ability to sit for prolonged periods.
Ability to reach, bend, lift, and carries medical records.
Good public relations and communication skills.
Good judgment when dealing with others.