Coder

Do you want to work at one of the Top 100 Hospitals in the nation? We are guided by our values of Love and Excellence and are passionate about delivering health, not just health care. Come join us at ChristianaCare!

ChristianaCare, with Hospitals in Wilmington and Newark, DE, as well as Elkton, MD, is one of the largest health care providers in the Mid-Atlantic Region. Named one of “America’s Best Hospitals” by U.S. News & World Report, we have an excess of 1,100 beds between our hospitals and are committed to providing the best patient care in the region. We are proud to that Christiana Hospital, Wilmington Hospital, our Ambulatory Services, and HomeHealth have all received ANCC Magnet Recognition®.

PRIMARY FUNCTION:

Responsible for accurate and timely assignment of  ICD-10 CM/PCS and HCPCS/CPT codes, payment group classification assignment and data abstraction for reimbursement purposes and statistical information reporting on all Inpatient, Outpatient, Emergency Medicine, Ancillary and Diagnostics records, and/or any other patient records for which HIMS Department performs coding services. 

PRINCIPAL DUTIES AND RESPONSIBILITIES:   

• Reviews and interprets Inpatient, Outpatient, Ancillary, Diagnostics and Emergency Medicine or other patient records in order to assign appropriate ICD-10 CM/PCS diagnosis and procedure codes and/or HCPCS/CPT procedure codes as required based on record type and CCHS reporting practices.

• Performs coding and abstracting tasks to support accurate and timely billing, data quality and statistics, and to support calculation for severity of illness and risk of mortality reporting. 

• Follows UHDDS definitions, CMS regulations and Official and Internal coding guidelines. 

• Utilizes information on diagnostic reports (i.e. radiology, pathology, EKG reports, laboratory values, doctors’ orders and administrative medication forms) to accurate code patient charts in accordance with the Official Coding Guidelines.

• Works within service line structure where applicable based on patient type.

• Abstracts pertinent data, determines and sequences codes for diagnoses and procedures, and enters all information into the computerized coding and abstracting system.

• Utilizes coding and abstracting system as a communication tool, as outlined in the HIMS Coding DNFB Tagging procedures, including but not limited to placing accounts on hold, to ask questions to management, and initiate queries.

• Receives feedback and reviews charts with a member of the Coding Management Team for accurate code assignment.

• Provides all necessary coded and abstracted information required for final coding and billing of accounts within productivity expectations by work type in order to support department and organization goals for DNFB dollar amounts and bill hold days.  

• Reviews prepopulated patient demographic information fed via HL7 from source system into coding system and makes necessary abstracted data changes in coding system as required for accurate posting to CCHS billing system.   

• Utilizes coding system to calculate all inpatient encounters in both MS DRG and APR DRG groupers to support the accurate reporting of coded data for severity of illness and risk of mortality.

• Utilizes coding system to sequence CPT codes invoking the APC grouper methodology to arrive at the proper CPT code hierarchy. 

• Submits timely, accurate and concise daily productivity reports in accordance with department policy and practice.  

• Attends and participates in coding section and department meetings, in service training sessions, seminars and workshops.

• Reports errors as identified in patient identification, account or encounter information, documentation or other medical record discrepancies as they are noted during daily work performance. 

EDUCATION AND EXPERIENCE REQUIREMENTS:

• College Diploma in Medical Coding or one year coding experience in a healthcare environment required.

• Associate or Bachelor Science degree in Health Information Technology preferred.

KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS:

• Knowledge of ICD and CPT Coding Guidelines and Principles

• Strong knowledge base of anatomy and physiology and medical terminology

• Working knowledge of pathophysiology and basic pharmacology

• Knowledge of Official Inpatient and Outpatient Coding Guidelines

• Ability to review medical records and make accurate decisions

• Ability to act independently within established guidelines

• Ability to maintain confidential information and materials

• Ability to exercise judgment, tact, and diplomacy

• Strong communication (written and verbal) and interpersonal skills (teamwork required)

• Ability to utilize computer systems/software applications as necessary

Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.