What are the responsibilities and job description for the CODER INPATIENT PER DIEM position at Carson Tahoe?
Description
US : NV : Carson City Medical Records
Per Diem Day Shift
About Carson Tahoe Health
CTH is a not-for-profit healthcare system with 240 licensed acute care beds, fully accredited by the Center for Improvement in Healthcare Quality (CIHQ). CTH was voted 5th most beautiful hospital in the nation nestled among the foothills of the Sierra Nevada in North Carson City and only a short drive away from world-famous Lake Tahoe & Reno. We serve a population of over 250,000 and feature two hospitals, two urgent cares, an emergent care center, outpatient services and a provider network with 19 regional locations.
Summary
As senior level coding specialist, assigns compliant, complete and accurate coding MS-DRG's, ICD-10-CM diagnosis codes, ICD-10-CM procedure codes, and Present on Admission (POA) indicators for the hospital inpatient, and LTACH on services based upon the clinical documentation provided within the medical record. Works collaboratively with other members of the Revenue Cycle to complete all essential responsibilities in a timely fashion to meet the quality, utilization, and financial needs of the organization. Ensures complete and accurate abstraction of the medical record data.
Responsibilities
- Ensures accurate, timely, and appropriate assignment of MS-DRG's, APR-DRG's, ICD diagnosis codes, ICD procedure codes, CPT, SOI and POA indicators, for the purpose of facilitating billing, internal and external reporting, research, and compliance with regulatory and payer guidelines.
- Keep up to date on best practices for coding and health information management practices.
- Adhere to regulatory (CMS) and other third party payer requirements pertaining to clinical documentation, coding and billing.
- Monitors and reviews regulatory changes that impact clinical documentation and reimbursement requirements to ensure accurate and compliant coding
- Clarify with the appropriate provider all incomplete, ambiguous, and / or conflicting clinical documentation when further specificity is needed for accurate and complete code assignment.
- Identify anatomy and physiology, clinical disease processes, pharmacology, and diagnostic terminology to assign accurate diagnosis and procedure codes. Search appropriate reference materials to obtain current information, guidance, and requirements as needed.
- Abstract accurately from the medical record all defined data elements such as diagnoses, procedures, attending physician, consultants, surgeons, discharge disposition, hospital service, etc.
- Works with other revenue cycle departments in identifying root causes of denials and claim rejections, as they relate to documentation and coding processes.
- Addresses questions or concerns posed by coders, clinicians, or other related departments regarding coding, charging, DRG assignments, APC assignments, modifier application, special projects, and other relevant topics
- Maintains or exceeds the standard level of quality and productivity established
- Assist with special projects as needed and performs related duties as assigned. Ability to multi-task with prioritization.
Qualifications
Required
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