Clinical Coding Specialist III-Health Information Management, Full Time Days

Cape Fear Valley Medical Center Fayetteville, North Carolina Health Information Management Clerical Days (United States of America) Reviews thoroughly the entire medical record to code specifically and accurately those conditions or diagnoses that were treated or affected the patient's plan of care. Verifies that each medical record contains appropriate documentation to justify the selected principal diagnosis to identify comorbid conditions, complications and procedures to use for DRG Assignment. Maintains an accurate case mix index from which administration makes critical management and strategic planning decisions.5 years coding experience required, preferably in a hospital setting. Two years inpatient coding preferred. Experience in a Health Information Management in an acute care facility, or with a Peer Review Organization, in Quality Assurance, or Utilization Review preferred. Bachelor's Degree in Health Information Management or equivalent training and experience. RHIA, RHIT, CCS or other equivalent credentials required. Medical terminology, anatomy and physiology, familiarity with medical record content and an understanding of the Uniform Hospital Discharge Data Set (UHDDS) definitions. Knowledge of ICD-CM coding principles under Prospective Payment System. Excellent communication skills required. Highly independent in that decisions are made with very serious impact affecting hospital reimbursement and PRO review determinations. High degree of interpretation, analysis, planning, coordination, and organization of information. Decisions require intense mental effort and consideration of reimbursement ramifications. Utilizes past experience, practices and organization to accomplish goals. Assigns accurate codes using good judgment in a timely manner within broad guidelines. Must be flexible and able to concentrate in a busy, noisy, and crowded environment with demands and interruptions 75% of the time.Near visual acuity required. Motor coordination required to operate computer. Work requires commuting between nursing units and Medical Record Department. RHIA - American Health Information Management Association