Location:

Miramar, Florida

Summary:

Utilizing an electronic medical record and computerized encoder, assigns and sequences diagnosis and procedure codes and present on admission indicators for inpatient encounters based on medical record documentation in accordance with Official Coding Guidelines, CMS regulations, encoder software guidance and Health Information Management (HIM) policies and procedures.

Responsibilities:

• Reviews appropriate inpatient coding work queues daily to address coding edits and needed corrections and follows procedure to notify billing as needed.
• Reviews accounts and performs needed correction for internal audits and external denials.
• Reviews inpatient medical records to assign and sequence all appropriate diagnosis and procedure codes utilizing encoder software and following official coding guidelines. Reviews Medicare Severity Diagnosis Related Groups (MSDRGs) and All Patient Refined Diagnosis Related Groups (APRDRGs) for appropriate code assignment.
• Formulates physician queries for validation of pathological findings. Requests clinical validation queries for Clinical Documentation Integrity (CDI) review and follow-up. Seeks clarification from providers or other designated resources to ensure accurate and complete coding.
• Attends educational meetings and seminars to maintain certification and continuing education requirements.
• Maintains strict adherence to patient confidentiality according to MHS Standards and regulatory requirements.
• Meet and maintain Memorial Healthcare System (MHS) coding quality and productivity standards. Submit daily productivity report to manager by defined deadline.
• Performs all other duties as requested.
• Reviews and validates accuracy of Admission-Discharge-Transfer (ADT) data fields; abstracts discharge disposition, physicians, procedure dates, and present on admission (POA) indicators.

Competencies:

ACCOUNTABILITY, ACCURACY (DRG), ACCURACY - CODER, CUSTOMER SERVICE, EFFECTIVE COMMUNICATION, HEALTH INFORMATION MANAGEMENT (HIM) SYSTEMS - CODER, PRODUCTIVITY - IP CODING, RESPONDING TO CHANGE, STANDARDS OF BEHAVIOR

Education and Certification Requirements:

High School Diploma or Equivalent (Required)Certified Coding Associate (CCA) - American Health Information Management Association (AHIMA)

Additional Job Information:

Complexity of Work: Requires critical thinking skills, effective communication skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action. Proficient in basic computer skills and ability to utilize a computerized encoder and electronic medical record system.Required Work Experience: Three (3) years inpatient coding experience in a hospital setting or a graduate of the MHS coder intern program.Other Information: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS).Additional Education Info: Focused education of hospital based coding.Additional Credential Info: Can be Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS).

Working Conditions and Physical Requirements:

• Bending and Stooping = 40%
• Climbing = 0%
• Keyboard Entry = 60%
• Kneeling = 40%
• Lifting/Carrying Patients 35 Pounds or Greater = 0%
• Lifting or Carrying 0 - 25 lbs Non-Patient = 40%
• Lifting or Carrying 2501 lbs - 75 lbs Non-Patient = 0%
• Lifting or Carrying > 75 lbs Non-Patient = 0%
• Pushing or Pulling 0 - 25 lbs Non-Patient = 40%
• Pushing or Pulling 26 - 75 lbs Non-Patient = 0%
• Pushing or Pulling > 75 lbs Non-Patient = 0%
• Reaching = 40%
• Repetitive Movement Foot/Leg = 0%
• Repetitive Movement Hand/Arm = 60%
• Running = 0%
• Sitting = 60%
• Squatting = 40%
• Standing = 60%
• Walking = 60%
• Audible Speech = 60%
• Hearing Acuity = 60%
• Smelling Acuity = 0%
• Taste Discrimination = 0%
• Depth Perception = 60%
• Distinguish Color = 60%
• Seeing - Far = 60%
• Seeing - Near = 60%
• Bio hazardous Waste = 0%
• Biological Hazards - Respiratory = 0%
• Biological Hazards - Skin or Ingestion = 0%
• Blood and/or Bodily Fluids = 0%
• Communicable Diseases and/or Pathogens = 0%
• Asbestos = 0%
• Cytotoxic Chemicals = 0%
• Dust = 0%
• Gas/Vapors/Fumes = 0%
• Hazardous Chemicals = 0%
• Hazardous Medication = 0%
• Latex = 0%
• Computer Monitor = 80%
• Domestic Animals = 0%
• Extreme Heat/Cold = 0%
• Fire Risk = 0%
• Hazardous Noise = 0%
• Heating Devices = 0%
• Hypoxia = 0%
• Laser/High Intensity Lights = 0%
• Magnetic Fields = 0%
• Moving Mechanical Parts = 0%
• Needles/Sharp Objects = 0%
• Potential Electric Shock = 0%
• Potential for Physical Assault = 0%
• Radiation = 0%
• Sudden Decompression During Flights = 0%
• Unprotected Heights = 0%
• Wet or Slippery Surfaces = 0%

Shift:

Primarily for office workers - not eligible for shift differential

Disclaimer:

This job description is not intended, nor should it be construed to be an exhaustive list of all responsibilities, skills, efforts or working conditions associated with the job. It is intended to indicate the general nature and level of work performed by employees within this classification. Wages shown on independent job boards reflect market averages, not specific to any employer. We encourage candidates to talk to their Memorial Healthcare System recruiter to discuss actual pay rates, during the hiring process. Memorial Healthcare System is proud to be an equal opportunity employer committed to workplace diversity. Memorial Healthcare System recruits, hires and promotes qualified candidates for employment opportunities without regard to race, color, age, religion, gender, gender identity or expression, sexual orientation, national origin, veteran status, disability, genetic information, or any factor prohibited by law. We are proud to offer Veteran's Preference to former military, reservists and military spouses (including widows and widowers). You must indicate your status on your application to take advantage of this program. Employment is subject to post offer, pre-placement assessment, including drug testing. If you need reasonable accommodation during the application process, please call 954-276-8340 (M-F, 8am-5pm) or email TalentAcquisitionCenter@mhs.net.