HIM Coder - On Site - PT

Position Summary:

The Coder is responsible for accurate abstracting of patient data into the computerized data base system (HCS) in accordance with the current principles of diagnosis and clinical coding guidelines. Requires skill in the sequencing of diagnoses/procedures to optimize reimbursement. Ensures that records are coded in an accurate and timely manner. The coder monitors the unbilled report and maintain compliance within the established turnaround time and resolves technical coding and sequencing problems as appropriate. The coder manages the flow of patient information as related to treatment, payment, and organizational needs, assists the Director of HIM with daily activities of the department, demonstrates the ability to process requests for information, maintains and filing of medical records.

Position Responsibilities:

Clinical / Technical Skills (40% of performance review)

• Ensures records are coded within 24-48 hours of discharge, excluding weekends and holidays.
• Reviews medical record thoroughly to ascertain all diagnoses/procedures are accurate.
• Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on medical record.
• Contribute to and maintain SUNs system standards.
• Query the Physicians when clarification or specification of a diagnosis is needed.
• Refers medical record to Director of HIM, if there is a question regarding the diagnoses/codes.
• Utilizes computerized coding/abstracting equipment (HCS & Tru-Code encoder).
• Codes all diagnoses/procedures in accordance ICD-10-CM coding principles and the Coding Manual.
• Inputs diagnoses, procedures and other abstracting data in HCS.
• Validates discharge status is correctly entered.
• Meets productivity standard of assigning codes to a minimum of three (2-3) medical records per hour on Medicare accounts and (4-6) medical records on non-federally funded accounts.
• Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded.
• Maintains 95% rate of information correctly abstracted.
• Assists the HIM Director with required survey reports.
• Maintains the number of DRG/coding changes below 3% quarterly threshold.
• Submit Medicare Records for Quarterly n-Thrive Coding audit.
• Participates in Quarterly post audit Education with n-Thrive.
• Periodically attends Tru-Code Educations.
• Notifies HIM Director whenever work is more than 48 hours behind work deadline.
• Ensures data quality and optimum reimbursement allowable under the federal and state payment systems.
• Acts as a resource person to Medical and hospital staff for documentation issues.
• Must be familiar with all medical record and coding requirements for Behavioral Health.
• Maintains a good working relationship within the department, other departments and medical staff.
• Notifies HIM Director when there are compliance issues with records.
• Assists with chart assembly/analysis
• Assists with re-analysis of physician deficiencies.
• Assists the department with Release of Information.
• Performs performance improvement functions through data collection and documentation review.
• Perform other duties as assigned.

Safety (15% of performance review)

• Strives to create a safe, healing environment for patients and family members
• Follows all safety rules while on the job.
• Reports near misses, as well as errors and accidents promptly.
• Corrects minor safety hazards.
• Communicates with peers and management regarding any hazards identified in the workplace.
• Attends all required safety programs and understands responsibilities related to general, department, and job specific safety.
• Participates in quality projects, as assigned, and supports quality initiatives.
• Supports and maintains a culture of safety and quality.

Teamwork (15% of performance review)

• Works well with others in a spirit of teamwork and cooperation.
• Responds willingly to colleagues and serves as an active part of the hospital team.
• Builds collaborative relationships with patients, families, staff, and physicians.
• The ability to retrieve, communicate, and present data and information both verbally and in writing as required
• Demonstrates listening skills and the ability to express or exchange ideas by means of the spoken and written word.
• Demonstrates adequate skills in all forms of communication.
• Adheres to the Standards of Behavior

Integrity (15% of performance review)

• Strives to always do the right thing for the patient, coworkers, and the hospital
• Adheres to established standards, policies, procedures, protocols, and laws.
• Applies the Mission and Values of SUN Behavioral Health to personal practice and commits to service excellence.
• Supports and demonstrates fiscal responsibility through supply usage, ordering of supplies, and conservation of facility resources.
• Completes required trainings within defined time periods.
• Exemplifies professionalism through good attendance and positive attitude, at all times.
• Maintains confidentiality of patient and staff information, following HIPAA and other privacy laws.
• Ensures proper documentation in all position activities, following federal and state guidelines.

Compassion (15% of performance review)

• Demonstrates accountability for ensuring the highest quality patient care for patients.
• Willingness to be accepting of those in need, and to extend a helping hand
• Desire to go above and beyond for others
• Understanding and accepting of cultural diversity and differences

Education

• Required: Associates degree, with a coding certification as a RHIT, RHIA, CCS, or CCA.
• Preferred: Bachelors Degree, with a coding certification as a RHIT, RHIA, CCS, or CCA.
• Maintains education and development appropriate for position

Experience:

• Required: Two (2) or more years of previous hospital experience as a Coder.
• Preferred: One (1) year of experience in a behavioral health setting as a Coder.