Coder III - Facility, Days

At Atrium Health Wake Forest Baptist, we take pride in offering a dynamic and fulfilling work environment. Joining our team means becoming an essential part of a leading healthcare institution that is committed to providing exceptional patient care and advancing medical research.

Position Highlights:

• Shift Schedule: Full time (40 hours),
• Department: Coding Education
• Location: Winston Salem, NC

What We Offer :

• Day 1 Health Coverage: Amazing health insurance with the option of copay or HSA eligible plans
• Wellness Incentives: Up to $1,350/year in wellness incentives through our LiveWELL program
• Education: Eligible for our Prepaid College Tuition Assistance program (up to $5,250/year)!
• Parental Benefits: Six weeks paid birthing-mother maternity leave & four weeks paid parental leave
• Retirement: Up to 7% employer-paid retirement contributions

Education/Experience/Certifications to Qualify:

• Graduation from an accredited medical coding program and two years of experience as an inpatient or ambulatory surgery coder in an acute care facility or demonstrated competency of knowledge base.
• Satisfactory completion of college level courses in anatomy, physiology and medical terminology preferred. EPIC health information system experience preferred.
• Coding certification CCA, CIC, CPC-H, CPC, CCS, RHIT, or RHIA required.

Essential Functions:

• Ensures the timely and accurate coding and completion of patient accounts within established departmental accuracy and productivity standards.
• Applies correct ICD CM/PCS (Inpatient) and ICD CM/CPT codes (Outpatient) guidelines meeting departmental policy regarding compliant methods, timeframes, use of applications and productivity.
• Assists in demonstrating medical necessity for procedures performed by ensuring that all documented disease processes are coded.
• Reviews facility charges as provided and edits where necessary to ensure charges are compliant and substantiated by provider documentation.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
• Queries physician when existing documentation is unclear or ambiguous following AHIMA guidelines and established policy. Brings identified concerns to Manager Coding for resolution.
• Assigns the MS DRG and MCC/CCs that most appropriately reflects documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department (Inpatient).
• Reviews department-specified reports daily to identify charts that need to be coded based and prioritizes as per department-specific guidelines and within designated timelines.
• Follows up to ensure that any edits that prevent an account from dropping are corrected within established timelines.
• Produces specific reports on a monthly basis per established parameters.
• Responds to inquiries from Patient Accounts or other departments as requested. Communicates with Manager when trending request volumes impact productivity.
• Participates in on site and/or external training workshops as opportunities arise; maintains credentials, if applicable, and submits written evidence of maintenance.
• Participates in training other coders. Acts as a mentor when assigned.
• Collaborates on cases where the final DRG and coded DRG differ, in order to resolve the difference (Inpatient).
• Works with the Health Records Specialists to identify opportunities for MS-DRG optimization when medically indicated (Inpatient).
• Participates in accurate data collection, evaluation and recommendations for process improvements.
• Participates as a member of the Clinical Documentation Management Program
• Assists Managers as requested.