Health Information Management Coder - Health Information Management

Location

John H. Stroger, Jr. Hospital

Health Information Management

7:00 AM - 3:00 PM

$37.658 hourly

Under the supervision of a Coding Supervisor, the Health Information Management (HIM) Coder abstracts relevant clinical and demographic information from the medical record to identify the care rendered to the patient for the purpose of reimbursement, research and compliance. The HIM Coder ensures that the medical record reflects accurate attending physician documentation for coding of physician and facility encounters. Assigns ICD-10-CM and PCS codes, CPT-4, and HCPCS Level II codes in accordance with coding and reimbursement guidelines for physician and facility encounters.

Abstracts into a group and assigns Diagnosis Related Group (DRG) on inpatient accounts and applies Ambulatory Payment Classifications (APC) to outpatient accounts. With minimal errors, identifies principal and secondary diagnosis and procedures based upon federally mandated requirements, corporate requirements, and hospital policy. Maintains productivity standards and quality accuracy of 95% or above.

• Identify and code the principal and secondary diagnosis and procedures using ICD-10-CM and PCS, E/M, CPT-4, and HCPCS Level II codes with minimal errors as needed.
• Sequence diagnoses and procedures in accordance.
• Abstract specific data and enter it into the clinical abstracting database.
• Utilize the encoder and other related databases and references to minimize coding errors.
• Attend departmental required in-service and training programs.
• Attend the hospital's annual in-service and training programs.
• Adhere to section/departmental procedures for work assignments.
• Meet quality and productivity standards.
• Adhere to the departmental standard practices guidelines.
• Adhere to hospital attendance policies.
• Adhere to environmental requirements.
• Meet the standard for compliance of continuing education (CE) as defined by the American Health Information Management Association (AHIMA) or other licensing/certification agencies.
• Perform assignments as scheduled with or without supervision.
• Maintain the confidentiality of information.
• Maintain a cooperative working relationship with the Health Information Management team.
• Work flexible hours, including weekends, holidays, and various shifts.
• Perform other duties as assigned, as required.

• A high school diploma or G.E.D., is required.
• One (1) year of coding experience within the last two (2) years, is required.
• Registered Health Information Administrator (RHIA) (AHIMA).
• Registered Health Information Technician (RHIT) (AHIMA).
• Certified Coding Specialist (CCS) (AHIMA).
• Certified Coding Specialist-Physician Based (CCS-P) (AHIMA).
• Certified Professional Coder (CPC) (AAPC).
• Must be able to work flexible hours, including weekends, holidays, and various shifts.

• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) is preferred.

• Knowledge of Microsoft Office Excel and Word.
• Working knowledge of ICD-9-CM and PCS, ICD-10-CM and PCS.
• Working knowledge of CPT-4.
• Working knowledge of HCPCS Level II codes.
• Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups.
• Ability to code utilizing a computerized encoder/abstracting system.
• Ability to operate a PC in a Windows environment.
• Ability to multi‑task and meet deadlines in a fast‑paced and stressful environment.
• Ability to adhere to department policies and standards using best practices.
• Ability to maintain a professional demeanor and composure when challenged.
• Ability to work flexible hours, including weekends.
• Ability to maintain a high level of discretion and confidentiality.
• Demonstrate attention to detail, accuracy and precision.

This position functions within a healthcare environment. The incumbent is responsible for adherence to all hospital and department-specific safety requirements, including personal protective equipment, hand washing and…