Seeking an EXPERIENCED Part-time Inpatient Coder opportunity.

Requires LOCAL candidate for REMOTE Opportunity after Initial On-site Training.

Job Summary

Supports, and is responsible for incorporating into job performance, the Frederick Health (FH) mission, vision, core values and customer service philosophy and adheres to the FH Compliance Program, including following all regulatory requirements and the FH Standards of Behavior.

Codes and abstracts inpatient medical records of all types and, following a rigorous review of the clinical documentation, abstracts and assigns appropriate ICD-10-CM/PCS code sets and assigns the correct APR-DRG into the hospital information system.May also code other work types as assigned by the Coding Manager.

Essential Functions:

·Determines the correct principal diagnosis, identifies and assigns co-morbidities and complications, secondary diagnoses, present on admission indicators for ICD-10-CM and MHACs (Maryland Hospital Acquired conditions), principal procedure codes and secondary procedure codes.

·Assigns the appropriate APR-DRG.

·Works in collaboration with CDI to ensure that the MHACS (Maryland Hospital Acquired Conditions) and PQIs (Prevention Quality Indicators) are correctly assigned.

·Identifies and correctly codes and sequences ICD-10- CM/PCS diagnoses and procedure codes for appropriate optimal reimbursement.

·Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information.

·Protects confidential medical information following HIPAA guidelines.

·Accurately abstracts the Attending Physician, Discharge Disposition and location Discharged to, Consultations, Ambulance Run Number & County codes, Date (s) of surgery or other procedures, Cause of Death if applicable, and Anesthesiologist.

·Writes compliant Queries to the physician when documentation is not clear or incomplete.

·Participates in an Abstract Peer Review to ensure that the abstract elements are correct

·Works in collaboration with other departments including Registration, Patient Financial Services, Lab, Pathology and Medical Records.

·Participates in Special Projects to include the Aging Report or review of denials.

·Meets Productivity Standards on a daily basis. (See Coding Productivity Standards)

·Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participating in continuing education programs to effectively apply ICD-10-CM and CPT coding guidelines to inpatient and outpatient diagnoses and procedures.

·Identifies the correct location in the medical record to obtain pertinent information such as (i.e. BMI, Hemodialysis, Blood Transfusion, Pressure Ulcers, Isolation, Mechanical Ventilation and orders.

·Keeps up-to-date on the HSCRC guidelines and state and national specific coding updates and guidelines.

·Maintain a thorough understanding of medical record practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO) and HSCRC (Health Services and Cost Review Commission).

Required Knowledge, Skills and Abilities:

• PC experience; ability to use computer terminals for prolonged periods to enter data.
• Ability to work under time and productivity constraints.
• Ability to work with frequent distractions/interruptions.
• Ability to read records and handwriting of differing levels of legibility for prolonged periods.
• Attention to detail.
• Good organizational skills.
• Ability to sit for prolonged periods.
• Ability to reach, bend, lift, and carry medical records.
• Good public relations and communication skills.
• Good judgment when dealing with others.

Minimum Education, Training, and Experience Required:

• High School Diploma or GED required.Completion of a Coding Certificate Program is required.
• At least one of the following: CCS (Certified Coding Specialist), RHIA or RHIT credential is required
• 5 to 10 years’ hospital coding experience which includes coding of inpatient records or a combination of inpatient and outpatient records using both ICD-10-CM and CPT is preferred.Demonstration of skills through completion of a hospital administered advanced coding test with a satisfactory score.

Physical Demands:

Sedentary - Light Work - Lifting up to 15 pounds on an infrequent basis (less than one lift every three minutes).While work is mostly done sitting, a certain amount of walking or standing is often necessary.

Ergonomic Risk Factors:

Repetition:Repeating the same motion over and over again places stress on the muscles and tendons.The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.

Awkward Posture:Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity.Awkward postures include repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions.

Working Conditions:

1. Blood borne Pathogens Exposure Risk:Category C – NO exposure to blood or body fluids

Reporting Relationship:

Reports to Manager