Hotline: 678-408-1354

SR MEDICAL RECORDS CODING SPECIALIST

Requisition #: 164654

Title: Medical Records Coding Specialist, Sr

Department: Health Information Management

Grade: ADM10

Posting Date: Aug 4, 2016

Status: Non-Exempt

Shift: Days

Union: SHARE

Hours: 40

Shift Length: 8 hours

Location: UMass Memorial Medical Center – 67 Millbrook St, Worcester, MA

UMass Memorial Medical Center is the region’s trusted academic medical center, and part of the UMass Memorial Health Care system. We are committed to improving the health of people in Central Massachusetts through excellence in care, comprehensive health services, teaching and research.

Position Summary:

Interprets a wide variety of clinical and diagnostic documentation, to include the most complex medical cases and treatments, identifying diagnoses, complications, comorbidities, and procedures for episodes of Inpatient care. Assigns appropriate ICD-CM (current edition) and ICD-PCS codes as appropriate adhering to Official Coding Guidelines. Assigns an appropriate DRG (Diagnosis Related Group) to each coded inpatient account to obtain optimal hospital reimbursement. This is the senior level inpatient Coding position.

Position Qualifications:

Level of knowledge equivalent to an Associate or Bachelor’s degree in Health Information Management, and an AHIMA certification; Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS) or Certified Coding Specialist – Physician (CCS-P), is required upon hire or within one year of hire. Certifications from the NHA, AAPC, or other professional Coding associations will be considered.

Knowledge of ICD-CM (current edition) and ICD-PCS coding systems required. Five years of medical coding experience or related work experience preferred. Knowledge of 3 rd party payer requirements and federal/state guidelines and regulations pertaining to coding and billing practices preferred.

Requires intermediate level computer skills with the ability to use computerized encoder and DRG Grouper software, standard office software applications, such as Microsoft Office Excel and Word.

Requires good interpersonal and communications skills and demonstrates professionalism when working with team members, management and other staff members.

Major Responsibilities:

Upon review of the entire clinical medical record, performs analysis on medical record documentation to include review of H&P, physician and nursing progress notes and flow sheets, physician orders, consultations, operative reports, pathology results, tests/reports and determines appropriate ICD-CM diagnosis codes (current edition) and ICD-PCS procedure codes as defined by coding guidelines, Coding Clinic, and other recognized reference materials.

Assigns the correct principal diagnosis, assigns co-morbidities and complications, secondary diagnoses, POA (present on Admission) indicators, HAC (Hospital Acquired Conditions), principal procedure codes, and secondary procedure codes according to official coding guidelines, Coding Clinic, and abiding by all official UHDDS definitions.

Based upon the assigned codes, utilizes the computerized encoder software to assign the most accurate DRG. The DRG assignment function requires coder to be knowledgeable of multiple payer-specific DRG groupers. The DRG assignment dictates the hospital’s reimbursement for each coded patient encounter billed.

Abstracts and enters all codes and required demographic information into the hospital’s abstracting database to complete patient’s abstract mandated by Federal and State regulatory agencies.

Keeps current with all Coding updates and information related to correct coding. Complies with HIM Policy #2001 for continueing education.

Initiates the Coding Query process when documentation is inconsistent, incomplete, ambiguous, or non-specific.

Works closely with the Clinical Documentation Improvement (CDI) team to improve medical record documentation.

Refers all unusual questionable situations to Lead Coder or other appropriate individual.

Informs supervisor when backlog situations arise, or necessary documents are either incorrect or are not being received in a timely manner.

Alerts management to any coding irregularities, or trends contrary to policy/procedure, so that corrective measures can be taken.

Assists in resolving incomplete and missing chart documentation in order to expedite chart abstraction and billing.

Maintains direct and ongoing communications with other coding personnel to maximize overall effectiveness and efficiency of the operation.

Complies with established departmental policies, procedures, and objectives.

Attends variety of meetings, conferences, seminars as required or directed.

Demonstrates use of Quality Improvement in daily operations.

Complies with all health and safety regulations and requirements.

Performs other similar and related duties as required or directed.

All responsibilities are essential job functions unless noted otherwise.

Contact Us

Eltas EnterPrises Inc.
3978 Windgrove Crossing
Suite 200A
Suwanee, Georgia
30024, USA
contact@eltasjobs.com

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