HIM CODER (Part-Time)

Description

JOB SUMMARY

Under the general direction of the HIM Coder Supervisor in collaboration with the Executive Director, HIM, Compliance & Policy Review, the HIM Coder will collate and code procedures and tests and ensure completeness and accuracy in the coding process in a timely manner and will support associated medical records functions in accordance with TJC, federal, state, and local guidelines, organizational and departmental policies, and procedures. Communicates with medical staff, other departments, and outside agencies while maintaining confidentiality. The position requires self-motivation, creativity, and capabilities to function in a semi-autonomous role within a fast-paced, efficient, and productive remote work environment.  

STANDARDS OF PERFORMANCE

1. Ensures adherence to proper infection control, OSHA and safety standards.
2. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to Official Coding Guidelines.
3. Queries physicians and other healthcare providers when code assignments are not straightforward or documentation is inadequate, ambiguous, or unclear for coding and legal health record purposes.
4. Requests any additional charges, test results, etc., from various departments to ensure timely coding on a daily basis.
5. Utilizes other EHS personnel to expedite any problems or questions that exist when necessary.
6. Maintains productivity levels as established by the Executive Director, HIM, Compliance & Policy Review with a minimum 95% accuracy rate on all coded records taking into consideration all test results and information provided by caregivers.  
7. Seeks out missing information and creates complete records, including items such as disease and procedure codes, point of origin code, discharge disposition, date of surgery, attending physician, consulting physicians, surgeons, and appropriate signatures/authorizations. Refers inconsistent patient treatment information/documentation to coding quality analysis, supervisor or individual department for clarification/additional information for accurate code assignment.
8. Completes assigned tasks in an appropriate timeframe and adjusts to increased workload. 
9. Code all records within three days of discharge unless records require more information for coding purposes.
10. Must be able to code at least 28 records per hour.
11. Follows up on questions and/or problems in order to code the record in a timely manner.
12. Demonstrates a consistent level of performance and a steady level of productivity while working remotely.
13. Participates in continuing education.
14. Handles coding for Method 2 Billing.
15. Complete the Performance Improvement Report for Method 2 Billing
16. Print all reports, MR Billing Report, Approved Claims Report, claims with missing information insurance report, Patient Index Report, Exceptions Report, and Incomplete Registration.
17. Document coding productivity.
18. Research policies for medical necessity.
19. Handles Business Services requests on claims.
20. Scan reports/records/data.
21. Handle the QA report from Business Office Services once a month.
22. Maintain the cancer registry.
23. Participates in performance improvement initiatives as assigned.
24. Performs other duties as necessary/required within scope of position and training.

Requirements

Minimum Level of Education: Education level equivalent to completion high school.

Formal Training: None.

Licensure, Certification, Registration: RHIA, RHIT, CCS, and or CPC required. CCA and CPC-A certification will be accepted but must obtain the certifications listed above within the timeframe set up by AAPC or AHIMA within 12 months of hire date.

Work Experience: Six months to one-year of experience in coding.