Overview Coder 4 provides inpatient coding utilizing ICD-10-CM and ICD-10 PCS Coding Classification systems. Utilizes an encoder and computer assisted coding (CAC) software to achieve accuracy and thorough coding. Researches complex coding scenarios and queries physicians on documentation for clarification. This is inpatient coding position for an experienced, trained inpatient coder. A Coder 4 analyzes clinical documentation; assign appropriate diagnosis, procedure, and abstract the codes and other clinical data. This information is then used to determine reimbursement levels, assess quality of care, study patterns of illness and injuries, compare healthcare data between facilities and between physicians, and meet regulatory and payer reporting requirements. Assist in the resolution of clinical documentation and provide feedback to providers on the quality of their documentation. Responsibilities Job Description Job Expectations: Code and abstract clinical and demographic data for inpatient admissions using standardized coding regulations/guidelines, abstracting rules, and Fairview guidelines. Utilizes technical coding principals and/or MS-DRG/APR-DRG reimbursement expertise to assign appropriate ICD-10-CM and ICD-10 PCS codes. Knowledge of relationship of disease management, medications and ancillary test results on diagnoses assigned. Identify and resolve clinical documentation and charge capture data discrepancies to improve quality of the clinical documentation, severity and reimbursement levels assigned, integrity of data reported. Assigns Present on Admission (POA) value for inpatient diagnoses and identifies non-payment conditions – Hospital Acquired Conditions (HAC) and ensures correct reporting. Query providers for additional documentation according to established procedures and guidelines in collaboration with the Clinical Documentation Integrity team. Assist in education of multidisciplinary team members, including physicians, as it pertains to frequently changing mandated rules, regulations and guidelines. Evaluate, problem-solve issues and/or discrepancies, and recognize when additional information or documentation is required to accurately code records Maintains knowledge of, and complies with, all relevant laws, regulations, policies, procedures and standards. Actively participates in creating and implementing improvements. Performs other responsibilities as needed/assigned. Validate computer assisted coding (CAC) codes for accuracy. Timely and accurate work. Collaborates with other Revenue Cycle Members to assure timely filing. Contributes to the process or enablement of collecting expected payment. Understands and Adheres to Revenue Cycle’s Escalation Policy. Collaborate with CDI staff to initiate queries and follow up with query resolution. Knowledge of SOI/ROM indicators, and awareness of how to improve these scores. Knowledge of PSI indicators. Organization Expectations, as applicable: Demonstrates ability to provide care or service adjusting approaches to reflect developmental level and cultural differences of population served Partners with patient care giver in care/decision making. Communicates in a respective manner. Ensures a safe, secure environment. Individualizes plan of care to meet patient needs. Modifies clinical interventions based on population served. Provides patient education based on as assessment of learning needs of patient/care giver. Fulfills all organizational requirements Completes all required learning relevant to the role Complies with and maintains knowledge of all relevant laws, regulation, policies, procedures and standards. Fosters a culture of improvement, efficiency and innovative thinking. Performs other duties as assigned Qualifications Minimum Qualifications to Fulfill Job Responsibilities: Required Education Certificate program in coding or Associate degree in HIM Experience One year of inpatient coding experience License/Certification/Registration One of the following: Registered Health Information Administrator (RHIA) Registered Health Information Technician (RHIT), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC) Preferred Education Associates or Bachelor’s degree in HIM Experience Two or more years of inpatient coding experience License/Certification/Registration Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Coding Specialist (CCS) Certified Inpatient Coder (CIC) Additional Requirements: Basic knowledge of Windows-based computer software. Due to differences in scope of care, practice, or service across settings, the specific experience required for this position may vary. Keeping up to date with CEU’s. EEO Statement EEO/AA Employer/Vet/Disabled: All qualified applicants will receive consideration without regard to any lawfully protected status