Job Summary:
Accounts for coding and abstracting of patient encounters, including diagnostic and procedural information, significant reportable elements and complications. Researches and analyzes data needs for reimbursement. Analyzes medical record and identifies documentation deficiencies. Serves as resource and subject matter expert to other coding staff.
Essential Responsibilities:
- Reviews and verifies documentation supports diagnoses, procedures and treatment results. Identifies diagnostic and procedural information.
- Audits clinical documentation and coded data to validate documentation supports services rendered for reimbursement and reporting purposes.
- Assigns codes for reimbursements, research and compliance with regulatory requirements utilizing guidelines. Follows coding conventions. Serves as coding consultant to care providers.
- Identifies discrepancies, potential quality of care, and billing issues. Researches, analyzes, recommends and facilitates plan of action to correct discrepancies and prevent future coding errors. Identifies reportable elements, complications and other procedures.
- Serves as resource and subject matter expert to other coding staff. Assists lead or supervisor in orienting, training, and mentoring staff. Provides ongoing training to staff as needed. Handles special projects as requested.
Basic Qualifications:
Experience
- Minimum two (2) years of hospital licensed space certified coding experience required.
Education
- High school diploma or General Education Diploma (GED) required.
- Post high school coursework in medical records administration, anatomy, physiology and medical terminology.
License, Certification, Registration
- Certified Professional Coder OR Certified Coding Specialist OR Registered Health Information Technician OR Registered Health Information Administrator
Additional Requirements:
- Experience with International Classification of Diseases (ICD-10 and ICD-10-PCS), Current Procedure Terminology (CPT4), and Healthcare Common Procedure Coding System (HCPCS) coding systems, and other related documentation requirements.
- Demonstrated ability to understand the clinical content of a health record.
- Knowledge of and experience in medical record department functions, diagnosis related groups, and prospective payment system.
- Demonstrated knowledge of and skill in word processing, spreadsheet and database PC applications.
Preferred Qualifications:
- Minimum three (3) years of hospital licensed space experience as a Certified Hospital Coder.
- Completion of an accredited Health Information Management program.
*Must reside in state of Hawaii or relocate to state of Hawaii prior to hire date.
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