The Jzanus Inpatient Coder will be responsible for accurately coding and abstracting diagnoses, procedures and clinical information from the medical record. The individual will adhere to established coding guidelines for data quality and integrity, as well as productivity.
The Inpatient Coder plays an integral role in ensuring accurate and compliant coding of inpatient records. This position requires an individual with attention to detail, strong analytical skills, effective communication and collaboration skills. Duties and responsibilities include but are not limited to:
-
Adherence to ICD9, ICD10CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic, CMS and other regulatory guidelines
-
Applying the Uniform Hospital Discharge Data Set (UHDDS) definitions including regulatory guidelines to select the principal diagnosis, secondary diagnoses, & procedures utilizing MSDRG, APRDRG reimbursement expertise to assign appropriate ICD10CM and/or ICD10PCS diagnoses and procedures.
-
Responsible for accurately assigning present on admission (POA) indicators for inpatient diagnoses.
-
Accurately identifying hospitalacquired conditions (HACs) supported in physician documentation and reportable to corresponding quality committees.
-
Verifying data and discharge disposition to assure coding compliance.
-
Formulate appropriate queries in accordance with Guidelines for Achieving a Compliant Query Practice (2019 Update) for clarification of conflicting/ambiguous documentation, treatments or diagnostic tests given to patients for accurate code assignment and sequencing.
-
Extracting required information from source documentation and enter into encoder and abstracting system.
-
Reviewing daily prebill edits and coding errors to make corrections or complete missing data elements.
-
Ability to collaborate with HIM Staff and Clinical Documentation Improvement Specialists (CDIS) to ensure the most accurate and complete documentation to support accurate coding/billing.
-
Efficiently utilize Coding software and HIMS to abstract required data from patient visits in the appropriate coding assignments and timely billing in accordance with DNFB goals and established hospital policy and procedures.
-
Attending continuing education workshops, webinars, etc., for coding compliance and maintenance of CEUs.
-
At least 5 years’ working experience with ICD10CM/PCS code sets and MSDRG and APRDRG payment models
-
Successful completion of at least one AHIMA (American Health Information Management Association) certified program with achievement of the correlating professional credential preferred (RHIA, RHIT, and / or CCS, etc.)
-
Associates or higherlevel degree in a Health Information Management discipline preferred
-
Prior experience working within a large hospital system (500 + beds), demonstrating familiarity with multiple service lines, facility coding guidelines, EMR platforms such as Epic and 3M360 software a plus
-
Candidates must have experience coding acute care Trauma/Teaching Level 1 Facility, Transplants Kidney, Liver and Pancreas, Surgical Services including Gen Med Surg, Ortho, Cardiothoracic, Vascular, Bariatric, Gynecologic, Neurologic, Urologic, Colorectal, Behavioral Health, Gastroenterology, and Wound Care
-
Meet coding productivity and accuracy requirements
-
A preemployment coding proficiency assessment will be administered
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
-
Stationary position: Must be able to remain in a stationary position for prolonged periods (e.g., eighthour shift) while working at a computer.
-
Repetitive motion: The employee must be able to constantly operate a computer and other office productivity machinery, which requires repeating motions that may include the wrists, hands, and/or fingers.
-
Communication: Must have the ability to frequently communicate (verbally and in writing) to exchange accurate information with peers, direct supervisors, and client(s).
-
Vision: Must possess near visual acuity to constantly review computer screens, medical records, and other digital documents.
-
Mobility (occasional): The person in this position may occasionally need to move about inside their dedicated workspace to access books, papers, or office machinery.
-
Dedicated workspace: Must provide a secure, and quiet workspace that is free from distraction and ensure PHI is protected.
-
Connectivity: Must maintain a reliable, highspeed internet connection at minimum of 200 Mbps and a functional office setup.
-
Environmental conditions: No adverse environmental conditions are expected.
For over 25 years, Jzanus has been a premier provider of revenue integrity HIM services. Quality and trust, along with personal and professional integrity have been the cornerstones upon which we built our reputation and our success. Jzanus’s accomplishments are the result of our New York best practice experience, our proprietary technology platform and most importantly the Jzanus team. Our people are senior level professionals with extensive provider, payer, clinical, HIM and home care experience who are very aware of the business challenges that face you daily. Jzanus Consulting specializes in providing HIM coding validation, clinical documentation improvement, and cost outlier recovery to hospitals and hospital-owned physician organizations. We have earned the trust of our customers by utilizing only the most qualified HIM consultants. By ensuring compliance and coding accuracy for optimal reimbursements, we provide significant value to our customers.
