What are the responsibilities and job description for the Certified Coder II position at Northwestern Medical Center?
Certified Coder II
JOB SUMMARY:
Reviews clinical documentation and diagnostic results as appropriate to extract data and apply appropriate ICD 10 CM, PCS, CPT and HCPCS codes for billing, internal and external reporting, research, and regulatory compliance. Under the direction of the Revenue Cycle Manager and HIM Supervisor, accurately codes inpatient and observation conditions and procedures as documented in the ICD Official Guidelines for Coding and Reporting, with expert knowledge of MCC/CC’s. Resolves error reports associated with billing process, identify and report error patterns, and, when necessary, assists in design and implementation of workflow changes to reduce billing errors.
PRE-REQUISITES:
Education: High school diploma or equivalent required. Completion of medical record coding from an accredited school required. CCS/CCA certification required.
Experience: Two years of coding work experience required.
RELATIONSHIPS:
Reports To: Revenue Cycle Manager. Health Information Management Supervisor
Supervises: N/A
Other Contacts: HIM and Internal Audit Coordinator, Leadership Team, Managers, Supervisors, Clinical Resource Nurses, all employees, Medical Staff, and the general public.
SCOPE:
Machinery or Equipment Used: 3M Grouper, personal computer, microfilm, scanner, fax, copier.
Physical Demands: Mostly sedentary work. Manual dexterity and mobility. Occasional reaching, stooping, bending, kneeling, crouching, lifting.
Working Conditions: Office environment, occasional pressure due to multiple call and inquiries, subject to many interruptions.
Required Protective Equipment: as situation dicates
ESSENTIAL FUNCTIONS:
1. Assigns codes for diagnoses, treatments, and procedures according to the appropriate classification system for all encounters as assigned.
2. Reviews appropriate provider documentation to determine principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures and utilizes technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD diagnoses procedures present on admission indicators, and all other applicable codes.
3. Extracts required information from source documentation and enters into encoder and abstracting system.
4. Identifies non-payment conditions (HAC) and when required, reports through established procedures.
5. Works interdepartmentally with Physicians and NMC Department representatives to help improve processes, documentation, and increase efficiency as needed.
6. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines as well as NMC Coding Policies and Procedures.
