Senior Clinical Coder Remote

Senior Clinical Coder - (Remote, Flexible Schedule)

Penn Medicine, University of Pennsylvania Health System

Penn Medicine is dedicated to our tripartite mission of providing the highest level of care to patients, conducting innovative research, and educating future leaders in the field of medicine. Working for this leading academic medical center means collaboration with top clinical, technical and business professionals across all disciplines.

• Position Summary:
  
  Codes and abstracts information from inpatient and outpatient records by careful analysis and adherence to official coding guidelines assuring appropriate reimbursement, compliance with regulations, and accuracy for clinical care analysis and provider profiling. Review coded medical records for coding and DRG accuracy by verifying that the principal diagnosis, secondary diagnoses, principal procedure, and secondary procedures have been assigned accurately and produce the highest level of reimbursement to which the facility is legally entitled.
  
  This shall be completed according to established coding guidelines and rules for reporting.
• Demonstrates commitment to the Standards of Ethical Coding as set forth by AHIMA. Assigns codes based upon clinical coding guidelines.
• Perform SMART audits on 100% flagged records. Perform focused audits as necessary. Perform disposition code assignment audits.
• Perform post discharge physician queries to assist in clarifying vague or unclear documentation. Keep data on query response rate.
• Provide SMART tool training to new coding staff and cross training to existing staff as needed.
• Research, review and respond to coding and coding quality issues and questions from various internal and external departments, in coordination with Clinical Coding Trainer and/or CDI Coding Liaison.
• Refer coding classification, HDM, and severity of illness assessment questions to management in a timely manner for determination and guideline development.
• Communicate with co-workers, management, physicians, and other hospital staff regarding clinical documentation and reimbursement issues.
• Summarize and report quality results and trending issues on a weekly basis during SMART workgroup meeting to Trainer, Supervisor and Liaison.
• Perform audits of ICD-10-CM and ICD-10-PCS codes to ensure charts are coded by adhering to coding conventions and official coding guidelines with 95% accuracy.
• Perform audits of DRGs to ensure accurate, optimal assignment with 95% accuracy; review the accuracy of all abstracted data to ensure key elements are abstracted correctly.
• Identify and communicate documentation issues and concerns that influence coding, DRG assignment, and severity of illness assessment to management as identified.
• Perform account completion activities (e.g., verify disposition, contacting providers for OP notes, answering coder questions, query completion, missing documentation) as needed to positively impact DNB.
• Assist with the weekly monitoring of WQ process and maintenance of the IP DNB.
• Participate in the development of institutional and organizational coding policies.
• Assign ICD-10-CM diagnostic, procedure codes with appropriate present on admission indicators to inpatient records, based upon the practitioner clinical documentation. Determine appropriate MS-DRG based upon diagnoses and procedure codes assigned.
• Assign ICD-10-CM diagnostic and CPT codes and modifiers to outpatient accounts.
• Abstract required clinical and demographic data from inpatient and outpatient records.
• The following duties are considered secondary to the primary duties listed above:
  Assist Patient Financial Services and physician offices with coding-related issues;
  Complete a productivity record daily and submit to Clinical Coding Supervisor weekly;
  Assist with appropriate capture of inpatient case mix.

• High school diploma or equivalent GED.
• Formal education in ICD-10-CM/PCS and CPT-4 coding, medical terminology, anatomy and physiology.
• Three to five years’ experience in ICD-10-CM and ICD-10-PCS coding principles/guidelines.
• Three to five years’ experience in MS-DRG assignment analysis and/or CPT coding…