Participates in basic coding education and training curriculum provided by Trinity Health's Health Information Management Department. Learns to analyze physician/provider documentation contained in Routine Outpatient (RO) health records (electronic, paper and hybrid) to determine the principal diagnosis, secondary diagnoses, principal procedure and secondary procedures. Develops skills to utilize encoder software applications, which includes all applicable online tools and references in order to assign International Classification of Diseases, Clinical Modification diagnosis and procedure codes and Current Procedural Technology / Healthcare Common Procedure Coding System (HCPCS) procedure codes.
Utilizes coding guidelines established by the Centers for Medicare/Medicaid Services (CMS), American Hospital Association (AHA) Coding Clinic, American Medical Association (AMA) for CPT codes and CPT Assistant, American Health Information Management Association (AHIMA) Standards of Ethical Coding, Revenue Excellence/Regional Health Ministry (RHM) Organization coding policies and Trinity Health Coding Manual (TBA).
Knows, understands, incorporates, and demonstrates the Trinity Health Mission, Vision, and Values in behaviors, practices, and decisions. Gains knowledge and experience to competently navigate the patient health record and other computer systems/sources in determination of appropriate diagnoses and procedures. Develops skills to code Routine Outpatient as primary training and work assignment utilizing encoder software and online tools and references, in assigning ICD, CPT-, and HCPCS codes. Gains familiarity with charge validation. Develops an understanding of and familiarity with retrospective edit tools that alert a coder to address possible coding and/or documentation issues related to submitted diagnosis and procedure information obtained from the health record. Increases communication skills to effectively work with clinical staff, physicians and office staff regarding documentation issues or needs. Identifies concerns and notifies appropriate leadership for resolution. Develops skills to understand the importance of recognizing and tracking issues, such as missing documentation or charges that require follow-up to facilitate coding in a timely fashion. Adheres to Trinity Health and RHM confidentiality requirements as they relate to the release of any individual or aggregate patient information. Performs other duties as assigned by Leadership. Maintains a working knowledge of applicable Federal, State and local laws/regulations; the Trinity Health Integrity and Compliance Program and Code of Conduct; as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical and professional behavior.
Completion of an AHIMA-approved coding program or an AAPC-approved coding program, or Associate’s degree in Health Information Management or a related field or an equivalent combination of years of education and experience is required. Bachelor’s degree in Health Information Management (HIM) or related healthcare field is preferred. Certified Coding Associate (CCA), Certified Procedural Coder Apprentice (CPCA), Certified Procedural Coder (CPC), Registered Health Information Technologist (RHIT), or Registered Health Information Administrator (RHIA within 12 months of the start date of employment is required. Basic knowledge of medical terminology, Anatomy and Physiology and diagnostic and/or procedural coding obtained either through current experience, coding education or a coding certificate program is preferred. Six (6) months to a one (1) year of current coding experience or experience working in a healthcare setting is preferred. Ability to use standard desktop and windows based computer system, which includes a basic understanding of e-mail, internet, and computer navigation. Ability to use other software as required to perform the essential functions on the job. Familiarity with distance learning or using web-based training tools desirable. Well-developed communication skills, both written and oral, that may be used either in on-site or virtual working environment. Able to communicate effectively with individuals and groups representing diverse perspectives. Strong problem solving skills. Must be comfortable functioning in a virtual, collaborative, shared leadership environment. Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of Trinity Health.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS
Must be able to set and organize own work priorities, and adapt to them as they change frequently. Must be able to work concurrently on a variety of tasks/projects in physical or virtual environments that may be stressful with individuals having diverse personalities and work styles. Must possess the ability to comply with Trinity Health policies and procedures. Must be able to spend majority of work time utilizing a computer, monitor, and keyboard. Must be able to perform some lifting and/or pushing/pulling up to 20 pounds if applicable. Must be able to work with interruptions and perform detailed tasks. If applicable, involves a wide array of physical activities, primarily walking, standing, balancing, sitting, squatting, and reading. Must be able to sit for long periods of time. Must be able to travel to various Trinity Health sites (10%) as applicable.