Sr Inpatient Coder
At Houston Methodist, the Senior Inpatient Coder position is responsible for ensuring diagnostic and procedure codes are assigned accurately to inpatient, emergency room, therapy, and/or clinic encounters based upon documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines. FLSA STATUS Non-exempt QUALIFICATIONS EDUCATION
- Associate’s degree or higher in a Commission on Accreditation for Health Informatics and Information Management accredited program or additional two years of experience (in addition to the minimum experience requirements listed below) in lieu of degree
EXPERIENCE
- Three years of relevant inpatient coding experience or successful completion of the Houston Methodist Senior Inpatient Coder Transition Program
LICENSES AND CERTIFICATIONS Required
- Must have one of the following:
- RHIT - Certified Health Information Technician (AHIMA)
- RHIA - Registered Health Information Administrator (AHIMA)
- CCS - Certified Coding Specialist (AHIMA)
SKILLS AND ABILITIES
- Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
- Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
- Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
- Knowledge of coding classification systems, DRG and APC systems, official coding guidelines and coding compliance
- Knowledge of an electronic medical record and imaging systems
- Working knowledge of medical terminology, anatomy and physiology
- Proficiency with electronic encoder application
- Extensive PC knowledge - must be able to work effectively in common office software, coding software and abstracting systems
ESSENTIAL FUNCTIONS PEOPLE ESSENTIAL FUNCTIONS
- Interacts and communicates effectively with members of the coding team and HIM, physicians, IT, Patient Access and Business Office.
- Participates and provides good feedback during coding section meetings and coding education inservices.
- Takes initiative to assist others and shares knowledge with the coding group, business office, physicians and nurses on official coding guidelines.
SERVICE ESSENTIAL FUNCTIONS
- Responds promptly to internal and external customer requests. Responds promptly to requests to code or review coded accounts for accuracy.
- Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process.
QUALITY/SAFETY ESSENTIAL FUNCTIONS
- Responsible for assigning diagnostic and procedural codes to encounters of high complexity.
- Maintains and achieves the highest standards of coding quality by assigning accurate ICD-9-CM/ICD-10-CM/ICD-10-PCS codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines.
- Maintains and achieves department standards of abstracting quality by reviewing accurate discharge disposition entered by nursing and corrects if necessary in order to achieve the highest quality of entered data. Assigns and enters physician identification number and procedure date correctly in the medical record abstracting system.
- Reviews medical record documentation and abstracts data into the encoder and EPIC/Electronic Health Record (EHR) to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions and procedures.
- Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official guidelines.
FINANCE ESSENTIAL FUNCTIONS
- Utilizes time effectively. Consistently codes and abstracts at or above departmental standards of productivity while ensuring accuracy of coding.
- Supports meeting organizational goal for Accounts Receivables (AR) associated with uncoded accounts.
- Maintains coding timeframes within established departmental standards by ensuring all work items assigned to the coding queues are processed in a timely manner.
GROWTH/INNOVATION ESSENTIAL FUNCTIONS
- Critically evaluates her or his own performance, accepts constructive criticism, and looks for ways to improve.
- Displays initiative to improve relative to job function. Contributes ideas to help improve quality of coding data and abstracting data.
SUPPLEMENTAL REQUIREMENTS WORK ATTIRE
- Uniform: No
- Scrubs: No
- Business professional: Yes
- Other (department approved): No
ON-CALL* • Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.
- On Call* No
TRAVEL** • *Travel specifications may vary by department** • May require travel within the Houston Metropolitan area Yes
- May require travel outside Houston Metropolitan area Yes
QUALIFICATIONS EDUCATION
- Associate’s degree or higher in a Commission on Accreditation for Health Informatics and Information Management accredited program or additional two years of experience (in addition to the minimum experience requirements listed below) in lieu of degree
EXPERIENCE
- Three years of relevant inpatient coding experience or successful completion of the Houston Methodist Senior Inpatient Coder Transition Program
LICENSES AND CERTIFICATIONS Required
- Must have one of the following:
- RHIT - Certified Health Information Technician (AHIMA)
- RHIA - Registered Health Information Administrator (AHIMA)
- CCS - Certified Coding Specialist (AHIMA)
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