Coder

Job Requisition #: JR59516

End Date: 9/1/2022

Location: Elkton, Maryland

Position Type: IT & Technical Operations

Shift: Day Shift, No Rotation

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PRIMARY FUNCTION:

Responsible for accurate and timely assignment of  ICD-10 CM/PCS and HCPCS/CPT codes, payment group classification assignment and data abstraction for reimbursement purposes and statistical information reporting on all Inpatient, Outpatient, Emergency Medicine, Ancillary and Diagnostics records, and/or any other patient records for which HIMS Department performs coding services. 

PRINCIPAL DUTIES AND RESPONSIBILITIES:   

Reviews and interprets Inpatient, Outpatient, Ancillary, Diagnostics and Emergency Medicine or other patient records in order to assign appropriate ICD-10 CM/PCS diagnosis and procedure codes and/or HCPCS/CPT procedure codes as required based on record type and CCHS reporting practices.

Performs coding and abstracting tasks to support accurate and timely billing, data quality and statistics, and to support calculation for severity of illness and risk of mortality reporting. 

Follows UHDDS definitions, CMS regulations and Official and Internal coding guidelines. 

Utilizes information on diagnostic reports (i.e. radiology, pathology, EKG reports, laboratory values, doctors' orders and administrative medication forms) to accurate code patient charts in accordance with the Official Coding Guidelines.

Completes daily work assignment as directed by Coding Support.

Works within service line structure where applicable based on patient type.

Abstracts pertinent data, determines and sequences codes for diagnoses and procedures, and enters all information into the computerized coding and abstracting system.

Utilizes coding and abstracting system as a communication tool, as outlined in the HIMS Coding DNFB Tagging procedures, including but not limited to placing accounts on hold, to ask questions to management, and initiate queries.

Receives feedback and reviews charts with a member of the Coding Management Team for accurate code assignment.

Provides all necessary coded and abstracted information required for final coding and billing of accounts within productivity expectations by work type in order to support department and organization goals for DNFB dollar amounts and bill hold days.  

Reviews prepopulated patient demographic information fed via HL7 from source system into coding system and makes necessary abstracted data changes in coding system as required for accurate posting to CCHS billing system.    

Utilizes coding system to calculate all inpatient encounters in both MS DRG and APR DRG groupers to support the accurate reporting of coded data for severity of illness and risk of mortality.

Utilizes coding system to sequence CPT codes invoking the APC grouper methodology to arrive at the proper CPT code hierarchy. 

Submits timely, accurate and concise daily productivity reports in accordance with department policy and practice.   

Attends and participates in coding section and department meetings, in service training sessions, seminars and workshops.

Reports errors as identified in patient identification, account or encounter information, documentation or other medical record discrepancies as they are noted during daily work performance. 

Utilizes general office equipment and computer systems and software applications as necessary to perform work functions.

Performs assigned work safely, adhering to established departmental safety rules and practices; reports to supervisor, in a timely manner, any unsafe activities, conditions, hazards, or safety violations that may cause injury to oneself, other employees, patients and visitors.

Performs other related duties as required.

SCOPE, PURPOSE, AND FREQUENCY OF CONTACTS:

Daily contact with intradepartmental personnel

Occasional contact with clinical, ancillary, and Information Services staff

Occasional contact with physicians and physician office staff

Occasional contact with the public

DIRECTION/SUPERVISION OF OTHERS:

None

DIRECTION/SUPERVISION RECEIVED:

Immediate:                         Coding Manager

Indirect:                              Coding Coordinator

                                             Coding Supervisor

                                             Associate Director Coding and Data Quality

Dept. Head:                        Corporate Director, HIMS

EDUCATION AND EXPERIENCE REQUIREMENTS:

College Diploma in Medical Coding or one year coding experience in a healthcare environment required.

Associate or Bachelor Science degree in Health Information Technology preferred.

KNOWLEDGE, SKILL, AND ABILITY REQUIREMENTS:

Knowledge of ICD and CPT Coding Guidelines and Principles

Strong knowledge base of anatomy and physiology and medical terminology

Working knowledge of pathophysiology and basic pharmacology

Knowledge of Official Inpatient and Outpatient Coding Guidelines

Ability to review medical records and make accurate decisions

Ability to act independently within established guidelines

Ability to maintain confidential information and materials

Ability to exercise judgment, tact, and diplomacy

Strong communication (written and verbal) and interpersonal skills (teamwork required)

Ability to utilize computer systems/software applications as necessary

SPECIAL REQUIREMENTS:

Ability to make decisions and apply judgment

Ability to work well with others as a team

Must be flexible, versatile, and adaptive

PHYSICAL DEMANDS:

Sitting for long periods of time utilizing a computer

Daily lifting or carrying large books (coding/reference books)

Frequent deadline situations requiring incumbent to work under pressure

Routine Office Environment

EEO Statement: Christiana Care Health System is an equal opportunity employer, firmly committed to prohibiting discrimination, whose staff is reflective of its community, and considers qualified applicants for open positions without regard to race, color, sex, religion, national origin, sexual orientation, genetic information, gender identity or expression, age, veteran status, disability, pregnancy, citizenship status, or any other characteristic protected under applicable federal, state, or local law.


UPDATE: ChristianaCare is committed to prioritizing the health and safety of our patients and caregivers. As we continue to meet the needs of our caregivers and our community through the COVID-19 pandemic, our commitment to health and safety requires that we take new steps to ensure a safe environment for medical care for our patients and a workplace that avoids preventable harm for our caregivers. For this reason, vaccination for COVID-19 is required for all caregivers at ChristianaCare and is considered a safety standard that is job-related and consistent with business necessity for all caregivers.

Why do WE offer careers full of possibilities?

For the Love of Health.

Inclusion & Diversity

At ChristianaCare, we’re committed to treating everyone with dignity and respect. We believe in a safe, inclusive work environment that fosters collaboration between caregivers from all walks of life. We know that each unique viewpoint is vital in delivering high-quality, safe patient care to everyone who walks through our doors. Our policies, benefits, hiring practices, employee resource groups, and corporate citizenship demonstrate our commitment to inclusion and diversity throughout our system.

Why do we embrace inclusion and diversity? For the Love of Health.

Our Values

We serve together in Love and Excellence. Our unique values, Love and Excellence are bold and powerful, and they are the reason why working for ChristianaCare is special. The behaviors associated with our values guide how caregivers interact with everyone they work with and make for an exceptional work experience. We believe that when you lead with Love, Excellence is inevitable.

Benefits

ChristianaCare’s comprehensive total rewards package is one of the most competitive in the region. We are proud to offer excellent benefits that reflect the organization’s commitment to being exceptional today and even better tomorrow.

At ChristianaCare, we provide access to high-quality and affordable benefits designed to meet our caregivers where they are. You can tailor your benefits to meet your needs now and adjust them as your priorities change.

Take advantage of ChristianaCare’s wide-ranging benefit offerings from supporting optimal health through medical, prescription, dental and vision coverage to valuable wellness and work/life programs, which include paid parental leave, coverage for infertility and assisted reproductive technologies, an employer-funded short-term disability program, and more.

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Our region offers a diversity of cultures, lifestyles, sports and entertainment events, housing options and educational opportunities. Located between Philadelphia and Washington, D.C., our locations provide easy access to two international airports, employment opportunities in a tri-state area, and proximity to some of the nation's top universities and colleges, as well as beaches in MD, DE and NJ!

Why Delaware? Why Maryland?
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For the Love of Health

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