Inpatient Coder IV

Position Summary:

The Coder IV is a member of the Health Information Management Team responsible for ensuring the accuracy and completeness of clinical coding, validating the information in the databases for outcome management and specialty registries, across the entire integrated healthcare system. The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual patient health information records for data retrieval, analysis and claims processing. This position is expected to perform duties in alignment with the mission and policies within the Dignity Health organization, TJC, CMS, and other regulatory agencies.

Principle Duties and Accountabilities:

• Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system for inpatient admissions.
• Can also code ancillary, emergency department, same-day surgery, and observation charts if needed.
• Review provider documentation to determine the principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures following official coding guidelines.
• Utilize technical coding principals and APC reimbursement expertise to assign appropriate ICD-IO-CM diagnoses, ICD-IO-PCS as appropriate, and CPT-4 for procedures.
• Understanding of ICD10 Coding in relation to DRGs
• Abstract additional data elements during the chart review process when coding, as needed
• Utilize technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD-10- CM diagnoses and ICD- IO-PCS procedures.
• Ensure accurate coding by clarifying diagnosis _and procedural information through an established query process if necessary.
• Assign Present on Admission (POA) value for inpatient diagnoses.
• Extract required information from source documentation and enter into encoder and abstracting system.
• Identifies non-payment conditions; Hospital-Acquired Conditions (HAC), Patient Safety Indicators (PSI) following, report through established procedures.
• Collaborate in the DRG Mismatch process with the Clinical Documentation Improvement team.
• Review documentation to verify and when necessary, correct the patient disposition upon discharge.
• Prioritize work to ensure the timeframe of medical record coding meets regulatory requirements.
• Serve as a resource for coding related questions as appropriate.
• Adhere to and maintain required levels of performance in both Coding accuracy and productivity.
• Review and maintain a record of charts coded, held, and/or missing
• Provide documentation feedback to Providers, as needed
• Participate in Coding department meetings and educational events.
• Meet performance and quality standards at the Coder III level.
• Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
• Other duties as assigned that have a direct impact on our ability to decrease the DNFB and support Revenue Cycle, including but not limited to charge validation, observation calculations, etc.

This is a remote position but selected candidate must reside in California.

Minimum Qualifications:

• High School Diploma or equivalent.
• Completion of an AHIMA or APPC accredited coding certification program that includes courses that are critical to coding success such as Anatomy and physiology, pathophysiology, pharmacology, Anatomy I Physiology, Medical Terminology, and ICD-10 and CPT coding courses, etc..
• Have and maintain current coding credential from AHIMA or AAPC (RHIA, RHIT, CCS, CCS-P, CPC, or CPC-H ).
• Three years of relevant coding and abstracting experience or an equivalent combination of education and experience required in an acute care hospital setting.
• A minimum of 3 years Inpatient medical coding experience (Hospital, Facility, etc).*
• Must have ICD-10 coding experience.
• Ability to use a PC in a Windows environment, including MS Word and EMR systems.
• Ability to pass coding technical assessment.

*One year of experience will be waived for those who have attended the Dignity Health Coding Apprenticeship Program.

Preferred Qualifications:

• Experience with various Encoder systems (i.e., OptumCAC, Cemer).
• Intermediate level of Microsoft Excel.
• Experience with coding and charge validation.

Dignity Health, one of the nation’s largest health care systems, is a 22-state network of more than 9,000 physicians, 63,000 employees, and 400 care centers, including hospitals, urgent and occupational care, imaging and surgery centers, home health, and primary care clinics. Headquartered in San Francisco, Dignity Health is dedicated to providing compassionate, high-quality, and affordable patient-centered care with special attention to the poor and underserved. For more information, please visit our website at www.dignityhealth.org. You can also follow us on Twitter and Facebook.

One Community. One Mission. One California