La Crescent, MN 55947
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Schedule Weekly Hours:40
We are seeking an experienced coder for our hospital inpatient team!
This is a 1.0 FTE = 80 hours every 2 weeks. This position will be working remote, however candidates must be within a reasonable driving distance to be able to come in for occasional meetings and training. We can only accept candidates from WI, IA and MN.
The Coding Specialist Hospital Services reads clinical documentation, diagnostic test results, procedure and treatment reports in hospital outpatient records and assigns ICD-10-CM, CPT and HCPCS-4 codes for hospital facility billing/reimbursement, internal and external reporting, research, and regulatory compliance. Under the direction of the supervisor of Hospital Coding Services, accurately assign codes to Hospital outpatient (same day surgery/procedure and observation) conditions and procedures in compliance with the ICD-10-CM Official Guidelines for Coding and Reporting. The specialist applies knowledge of the ICD-10-CM coding guidelines and the surgery section with the CPT coding system to the clinical findings documented in the patient medical record. Applies appropriate Hospital modifiers. The Coding Specialist 3 will utilize standard query and clarification processes to assure consistency between documentation, charges and assigned codes. Validates and abstracts defined data as required by the organization or by regulation. Adheres to the AHIMA Standards of Ethical Coding and the official coding rules and guidelines. Upon achieving entry level competency and demonstrating consistent performance in all other performance standards, the employee may request to work from a home-based office. If the request is granted, employee will comply with all provisions of the agreement. Occasional travel to Gundersen Health System facilities will be required.
1. Applies knowledge of coding guidelines, disease processes, anatomy and physiology, to select and assign the most appropriate diagnostic and procedural codes to hospital outpatient encounters. The patient encounters are generally short (1 day) and primarily for a single treatment or clinical problem. Codes are entered into the coding workstation for billing, research, planning, and quality improvement. Applies appropriate Hospital modifiers.
2. Adheres to the ICD-10-CM (International Classification of Diseases, 10th revision, Clinical Modification) coding conventions, official coding guidelines approved by the Cooperating Parties, the CPT (Current Procedural Terminology) rules established by the American Medical Association, the AHIMA Standards of Ethical Coding and any other official coding rules and guidelines.
3. Assesses the completeness and consistency of documentation in support of the medical necessity for the outpatient services provided and code assignment. If incomplete or conflicting clinical documentation is identified, utilize standard query processes to contact providers for additional information for clarification and additional documentation prior to code assignment.
4. Verifies and collects abstract data at the time of coding, entering changes into the hospital information system.
5. Collects and enters quality indicator data at the time of coding, in support of The Joint Commission, CMS core measures and other indicator systems.
6. Takes the initiative to develop and build coding competency by staying abreast of advances in medical practice and technology, coding guidelines and regulations. Obtains continuing education and maintains current certification through AHIMA.
7. Participates in the coding quality control program and completes reviews within the specified time frames.
8. Assists in the clinical training of Health Information Management students and training new coding employees.
9. Recommends or develops education for physicians and other clinicians regarding documentation practices that contribute to accurate and efficient code assignments.
10. Specialized certification will be required for Emergency Services coders.
11. Performs other job duties as requested.
Education and Learning:
Post High School education in a specialized field: Completion of Health Information Technician program or Completion of Health Information Administrator program or Equivalent allied health education
6 months Experience performing ICD 10 and CPT coding of hospital records in an educational or healthcare setting.
3-4 years 3-4 years hospital coding experience; could be professional services or facility coding, outpatient or inpatient. Experience using electronic healthcare record, encoder experience, ICD Outpatient Coding Guidelines, CMS Observation coding rules and APC optimization experience.
License and Certifications:
Registered Health Information Administrator (RHIA) within 12 months of hire date or Registered Health Information Technician (RHIT) within 12 months of hire date or Certified Coding Specialist (CCS) within 12 months of hire date
Age Specific Population Served:
Nonage Specific (N/A)
Category III - No employees in this job title have a reasonably anticipated risk of occupational exposure to blood and/or other potentially infectious materials.
Not substantially exposed to adverse environmental conditions (as in typical office or administrative work).
Physical Requirements/Demands Of The Position:
Sitting Continually (67-100% or 8 hours)
Repetitive Actions - Pinch Forces Continually (67-100% or 8 hours)
Repetitive Actions - Fine Manipulation Continually (67-100% or 8 hours)
If you need assistance with any portion of the application or have questions about the position, please contact [email protected] or call 608-775-0267
Equal Opportunity Employer