Coder III - Facility / HB, Full Time Days
Winston Salem, NC, United States
Job ID: 127728
Job Family: Medical Records Services
Status: Full Time
Shift: Day
Detailed Shift and Schedule: 7:00AM to 3:30PM
Job Type: Regular
Department Name: 55811088941310-Coding Inpatient Facility
Overview
At Atrium Health Wake Forest Baptist, we take pride in offering a dynamic and fulfilling work environment. Joining our team means becoming an essential part of a leading healthcare institution that is committed to providing exceptional patient care and advancing medical research.
Position Highlights:
- Shift Schedule: Full Time Days
- Department: Coding Inpatient Facility
- Location: Winston Salem Medical Center, NC
What We Offer:
- Day 1 Health Coverage: Amazing health insurance with the option of copay or HSA eligible plans
- Wellness Incentives: Up to $1,350/year in wellness incentives through our LiveWELL program
- Education: Eligible for our Prepaid College Tuition Assistance program (up to $5,250/year)!
- Parental Benefits: Six weeks paid birthing-mother maternity leave & four weeks paid parental leave
- Retirement: Up to 7% employer-paid retirement contributions
Education/Experience/Certifications to Qualify:
- Graduation from an accredited medical coding program and two years' experience as an inpatient or ambulatory surgery coder in an acute care facility or demonstrated competency of knowledge base.
- Satisfactory completion of college level courses in anatomy, physiology and medical terminology preferred.
- EPIC health information system experience preferred.
- Coding certification CCA, CIC, CPC-H, CPC, CCS, RHIT, or RHIA required.
Essential Functions:
- Ensures the timely and accurate coding and completion of patient accounts within established departmental accuracy and productivity standards.
- Applies correct ICD CM/PCS (Inpatient) and ICD CM/CPT codes (Outpatient) guidelines meeting departmental policy regarding compliant methods, timeframes, use of applications and productivity.
- Assists in demonstrating medical necessity for procedures performed by ensuring that all documented disease processes are coded.
- Reviews facility charges as provided and edits where necessary to ensure charges are compliant and substantiated by provider documentation.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
- Queries physician when existing documentation is unclear or ambiguous following AHIMA guidelines and established policy. Brings identified concerns to Manager Coding for resolution.
- Assigns the MS DRG and MCC/CCs that most appropriately reflects documentation of the occurrence of events, severity of illness, and resources utilized during the inpatient encounter and in compliance with department (Inpatient).
- Reviews department-specified reports daily to identify charts that need to be coded based and prioritizes as per department-specific guidelines and within designated timelines.
- Follows up to ensure that any edits that prevent an account from dropping are corrected within established timelines.
- Produces specific reports on a monthly basis per established parameters.
- Responds to inquiries from Patient Accounts or other departments as requested. Communicates with Manager when trending request volumes impact productivity.
- Participates in on site and/or external training workshops as opportunities arise; maintains credentials, if applicable, and submits written evidence of maintenance.
- Participates in training other coders. Acts as a mentor when assigned.
- Collaborates on cases where the final DRG and coded DRG differ, in order to resolve the difference (Inpatient).
- Works with the Health Records Specialists to identify opportunities for MS-DRG optimization when medically indicated (Inpatient).
- Participates in accurate data collection, evaluation and recommendations for process improvements.
- Participates as a member of the Clinical Documentation Management Program
- Assists Managers as requested.