drjobs Guidance Document Integrity - Facility Coding Remote

Guidance Document Integrity - Facility Coding Remote

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1 Vacancy
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Job Location drjobs

Charlotte - USA

Monthly Salary drjobs

Not Disclosed

drjobs

Salary Not Disclosed

Vacancy

1 Vacancy

Job Description

Description

Job Summary

Reviews clinical documentation and diagnostic results as appropriate to extract abstract data and apply appropriate ICD9CM/ICD10CM/PCS and CPT 4 codes for reimbursement and external reporting research regulatory compliance medical necessity CCI NCCI and any other regulatory edits. Code and abstract medical records of high complexity within the Primary Enterprise acute care facilities.



Essential Functions

  • Reviews medical records of high complexity to identify the appropriate principal diagnosis and procedure codes all other appropriate secondary diagnoses and procedure codes. Assign and present on Admission Hospital Acquired Condition and Core Measure Indicators for all diagnosis codes.
  • Facilitates appropriate MSDRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines.
  • Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an onsite or remote setting.
  • Reviews charges and Evaluation and Management levels.
  • Demonstrates proficiency with Microsoft Office Applications and in using required computer systems with minimal assistance.
  • Abstracts coded data and other pertinent fields in the hospital electronic health record.
  • Ensures the accuracy of data input.
  • Meets established quality and productivity standards.
  • Facilitates peer review and training for all Acute Clinical Coders in the coding department. Provides support to management.
  • Stay abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding.

Physical Requirements

Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment.

Education Experience and Certifications.
High school diploma or GED required; Bachelors degree preferred. Advanced knowledge in Medical Terminology Anatomy and Physiology and Pharmacology required. 4 years coding experience in acute care setting required. Current RHIA RHIT CCS CPCH CPC or CIC required plus a passing score on the Coding test.


Employment Type

Full-Time

Company Industry

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