HIM Coder II

General Summary

Reviews electronic health records to retrieve, collect, and assign appropriate ICD-10-CM diagnoses and CPT codes, by careful review and analysis of medical documentation of emergency department, ambulatory surgery, observation and invasive procedure outpatient records for the purposes of compliance with regulations, data and statistical compilation, clinical research, clinical care analysis, provider profiling and optimal reimbursement.
The ideal candidate will have ICD-10 CM coding, CPT, and IV (infusion) experience.

Duties and Responsibilities

Essential Functions:

• Reviews documentation in current electronic health record to accurately code and sequence diagnosis codes according to "ICD-10-CM Official Guidelines for Coding and Reporting" and to support medical necessity.
• Assigns appropriate first-listed and secondary CPT/HCPCS codes and modifiers for outpatient surgical and invasive procedures according to CPT, OCE/NCCI and department coding guidelines.
• Uses 3M encoding software and on-line references to review and resolve coding compliance edits and follow instructional notes to ensure accurate coding of accounts, modifier assignment and adherence with CPT bundling guidelines.
• Works cooperatively with medical staff and other healthcare professionals in obtaining documentation to complete medical records and ensure optimal and accurate coding. Communicates effectively with medical staff through use of electronic queries per established departmental policy.
• Abstracts clinical data, including Attending Physician, Surgeon, consultants, and discharge disposition for accurate reporting and claim submission.
• Reviews, validates, corrects, and posts charges for Interventional Cardiology or Interventional Radiology accounts based on review of medical documentation and procedure logs to ensure accurate coding and charging of procedures, devices, implants, and supplies. Proactively communicates with physicians, Cardiac Cath Lab staff and Sourcing and Contracting Department to ensure accuracy of documentation, supply information and costs.
• Reviews medication administration records and accurately posts infusion administration charges for observation, outpatient oncology and infusion service accounts according to Coding Infusion Guidelines.
• Works assigned account, charge review, or claim work queues to code accounts, investigate Epic claim edits or reason for denial and reviews Epic documentation to institute appropriate course of action. Works with billing and ancillary departments to resolve billing edits and inquiries.

Common Expectations:

• Maintains job specific standards and expectations relative to productivity and quality.
• Maintains established policies and procedures, objectives, quality assessment and safety standards.
• Participates in educational programs and in-service meetings.
• Maintains professional growth and development and professional credentials.
• Provides outstanding service to all customers; fosters teamwork; and practices fiscal responsibility through improvement and innovation.

Qualifications

Minimum Education:

• High School Diploma or GED Required
• Associates Degree Preferred or
• Bachelors Degree Preferred

Work Experience:

• 1 year Relevant CPT coding experience. Required

Licenses:

• Certified Coding Associate Upon Hire Required or
• Certified Professional Coder Apprentice Upon Hire Required or
• Certified Professional Coder Upon Hire Required or
• Certified Coding Specialist Upon Hire Required or
• Certified Coding Specialist - Physician Based Upon Hire Required or
• Certified Interventional Radiology Cardiovascular Coder Upon Hire Required or
• Registered Health Information Technician Upon Hire Required or
• Registered Health Information Administrator Upon Hire Required

Knowledge, Skills, and Abilities:

• Knowledge of ICD-10 and CPT coding; knowledge of medical terminology, anatomy, and physiology;
• Basic computer skills

Benefits Offered:

• Comprehensive health benefits
• Retirement savings plan
• Paid time off (PTO)
• Education assistance
• Financial education and support, including DailyPay
• Expanded Paid Parental Leave

For additional details: Benefits & Incentives | WellSpan Careers (joinwellspan.org)