Clinical Coder (Onsite)

Job Title: Clinical Coder

Location: Johnson County Hospital Tecumseh Nebraska

Department: Health Information Management

Reports To: HIM Manager

Work Schedule: Working hours are scheduled Monday-Friday. Hours may vary due to workload. Use of overtime is discouraged unless required for patient care needs. Overtime must be approved by immediate supervisor.

Position Summary:

Accountable for conversion of diagnoses and treatment procedures into codes using an international classification of diseases. Requires skill in sequencing of diagnosis/procedures. Ensures that records are coded in an accurate and timely manner for data retrieval analysis and claims processing.

Duties & Responsibilities:

• Knowledgeable of all charting and coding requirements including Acute care Swingbed and outpatient services.
• Ensures that records are coded accurately and timely within four (4) days of discharge excluding weekends and holidays.
• Reviews medical record thoroughly to ascertain all diagnoses/procedures.
• Abstracts pertinent information from patient records. Assigns ICD-10-CM or HCPCS codes in accordance to the ICD-10-CM/CPT coding principles and the Coding Manual.
• Queries physicians when code assignments are not straightforward or documentation in the record is inadequate ambiguous or unclear for coding purposes.
• Contacts responsible provider in a professional tactful manner.
• Coders diagnoses and procedures on clinical summary agree with physicians preference.
• Logs diagnoses procedures and other abstracting data for registers according to State reporting guidelines.
• Refers to HIM Coding Lead or HIM manager if there is a question regarding the diagnoses/codes.
• Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department manager for resolution.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Demonstrates proficiency in coding and abstracting software/encoder.
• Utilizes coding references available. Reviews coding periodicals within seven (7) days of receipt.
• Analyzes records for completeness and accuracy according to department and hospital policy and procedures for physician and nursing completion.
• Notifies physicians and nursing departments of delinquent or deficient medical records.
• Follows up on incomplete records within one week of notification.
• Runs deficiency analysis reports and other abstracting as requested by HIM manager.
• Performs final qualitative chart analysis to ensure all required documentation has been completed.
• Performs quantitative chart analysis to ensure accuracy of documentation pertinent to encounter and accurate record preparation for coding.
• Collaborates with Admission staff Billing staff Coding Lead and HIM Director as necessary for patient accounts requiring attention for timely and optimal hospital payment.
• Performs quality improvement functions through data collection and documentation review.
• The HIM Coder will understand and demonstrate compliance with HIPAA regulations and will comply with all JCH policies and procedures.
• The HIM Coder will carry out any other responsibilities deemed necessary by the HIM Director.

Qualifications & Skills:

• Preferred level of Education: Successful completion of coding certificate program in a program with AHIMA approval status; RHIA RHIT CCS CCS-P CCA certification status preferred.
• Minimum level of Education: Medical Terminology Anatomy & Physiology Coursework.
• Prefer work experience as a coder or strong training background in coding and reimbursement.
• Technical skills and proficiency with spreadsheets databases and EHR software communication customer service time management critical thinking and troubleshooting skills.
• Understanding of data gathering structuring categorization and manipulation.
• Ability to research billing and coding regulations and resources.
• Good business communication skills professional telephone techniques and patient relations.
• Able to treat others with respect and consideration.
• Requires professionalism.
• Be an active team member and support each member and the team as a whole.

Benefits We Offer:

• Competitive wages
• Comprehensive health dental and vision insurance
• Retirement savings plan
• Professional development opportunities
• Supportive and collaborative work environment
• Paid time off
• Sick pay

Why Join Us

At Johnson County Hospital we value our team and foster a supportive environment where you can thrive. Join us to make a difference in the lives of our patients and their families.