Location: Remote
Schedule: 8am ET to 5pm ET
Pay: $30 to $35 per hour, D.O.E.
Position Summary: The HIM Clinical Coder II (Certified) is responsible for timely and accurate assignment of ICD-10-CM, CPT-4, HCPCS, and APC Modifier. This role also assigns codes to all complex records such as SDCs, cardiac catheterization, recurring, anesthesia, and chemotherapy and radiation oncology. This classification is distinctly different than the HIM Clinical Coder I by coding all high dollar charts and discharges with a length of stay exceeding three (3) days. Coding and abstracting duties are performed in compliance with hospital, departmental, regulatory and national coding compliance, and accrediting guidelines. This position works in conjunction with the HIM Technicians in reference to missing documentation and transcribed reports. The HIM Clinical Coder II (Certified) works directly under the supervision of the HIM Manager or HIM Supervisor. This position represents the Health Information Management in court as Custodian of Records. The HIM Clinical Coder II (Certified) assumes responsibility and accountability for the duties and is cognizant of the philosophy, standards, objectives, and policies of the Medical Center and the Health Information Management Department.
Hazards & Physical Requirements: Work in this category is majorly sedentary and involves sitting, some standing and walking; employee may be required to lift or pull up to 10 lbs. frequently or 20 lbs. occasionally.
Education & Experience: Any combination of a High School Diploma or equivalent and familiarity with healthcare administrative office setting with 5 years coding experience. Hospital based coding credentials required.
Specific Requirements: Certified Coding Specialist (CCS), Certified Professional Coder-Hospitals (CPC-H) required.
Duties and Responsibilities:
• Performs the functions of a certified coder which requires coding charts and discharges with hospital stays for more than 3 days.
• Focuses on coding high dollar and complex charts for lengthy hospital stays.
• Assist HIM Coder I with coding complex charts for one (1) to three (3) day hospital stays.
• Uses every available resource to code and abstract medical records timely and accurately.
• Demonstrates the understanding of the coding and abstracting process by assigning the appropriate ICD-10-CM, CPT-4, HCPCS and APC Modifier codes to all outpatient and inpatient encounters.
• Follows the hospital policies and procedures using sound coding judgment based on industry coding guidelines and regulations.
• Follows the most current AHA coding Clinic Guidelines and the UHDDS Official Guidelines for coding and reporting diagnoses and procedures.
• Configures professional E&M service levels based on record documentation and enters corresponding codes/charges appropriately into the system.
• Keeps abreast of all coding compliance guidelines and semi-annual updates through ongoing education and independent research as required to maintain coding certification.
• Queries physicians when code assignment is not straight forward or documentation is inadequate or ambiguous for coding purposes.
• Communicates with the HIM Manager or HIM Supervisor regarding daily assigned tasks.
• Checks email and other memos daily for department and hospital communication.
• Effectively collaborates with HIM Technician III in reference to pending dictation or documentation for coding.
• Reviews and verifies all accounts with an abstract status of In-Process as assigned by HIM Manager or HIM Supervisor.
• Verifies the 5-days report as assigned by the HIM Manager or HIM Supervisor.
• Reports and maintains accurate productivity levels and meets department productivity and quality standards.
• Ability to function temporarily in other HIM roles as department workloads require without reservation.
• Ability to perform other related HIM duties as assigned.
Firstsource is an Equal Employment Opportunity employer. All employment decisions are based on valid job requirements, without regard to race, color, religion, sex (including pregnancy, gender identity and sexual orientation), national origin, age, disability, genetic information, veteran status, or any other characteristic protected under federal, state or local law.
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