Professional Coder

Description

Your passion belongs at UNC Health. Join more than 56,000 teammates working together to improve the health and well-being of the communities we serve across North Carolina.

Summary:

Assures data quality by coding and sequencing diagnoses, treatments and procedures for optimal reimbursement and validating key data elements for accurate statistics.

Responsibilities:

1. Ensures accuracy of key data elements needed for reimbursement and statistical needs of the hospital.

• a. Abides by the Standards of Ethical Coding set forth by AHIMA and adheres to official ICD-10-CM/PCS and CPT coding and reporting guidelines, when assigning codes and sequencing diagnoses, treatments and procedures for accurate, optimal, and timely reimbursement for the hospital
• b. Verifies key data information and enters into computer assisted software and/or electronic medical record
• c. Reviews documentation to verify and correct disposition upon discharge
• d. Works to resolve patient financial services issues involving patient accounts
• e. Reviews and corrects claim and SMART review edits
• f. Assigns present on admission (POA) value for inpatient diagnoses
• g. Consistently maintains daily productivity. Rating for these types of records: Inpatient: 15 to 25 records per day ER: 100 to 130 records per day (includes outpatient records), Ambulatory Surgery: 40 to 60 records per day, OBS: 40 to 50 records daily.
• h. Maintains a 95% accuracy rate on all records coded.

2. Maintains communication

• Seeks help from physicians as needed to clarify documentation in the medical record.
• Assists with the training of new employees, when needed.
• Assists with the education of clinical affiliation students related to coding and reimbursement issues.
• Assists with clinical documentation improvement, CDI program as needed.

• Physicians are consulted whenever documentation is unclear, particularly as it pertains to DRG assignment. Appropriate reference materials are used prior to consulting the physician. (Also consults with physician office staff concerning CPT assignment on an as needed basis.)
• Good communication skills are used inter and intra departmentally. Promotes harmony and teamwork among coworkers and others.

3. Maintains a current knowledge of coding guidelines and DRG assignment.

• Reads and utilizes all relevant changes in coding practices through literature such as The Coding Clinic, software updates, and coding teleconferences/workshops.

Other information:

• EDUCATION
• A two year degree in Health Information Technology or four year degree in Health Information Management required.
• EXPERIENCE

• Previous experience in ICD-10-CM/PCS and CPT coding in an acute care setting is preferred
• Previous EPIC, Optum, & SMART software experience preferred.
• LICENSURE/REGISTRATION/CERTIFICATION
• One AHIMA recognized credential, RHIT, RHIA, or CCS (eligible) required
• Successful completion of certification exam within 18 months of hire date required.
• OTHER SKILLS AND QUALIFICATIONS
• Can proficiently code charts from primarily one setting (inpatient or outpatient)
• Developed knowledge of anatomy, physiology and medical terminology
• UHDDS coding and reporting guidelines and ability to apply
• Basic computer literacy and familiarity with the keyboard.

Legal Employer: Lenoir Health

Entity: UNC Lenoir Health Care

Organization Unit: Coding Services

Work Type: Full Time

Standard Hours Per Week: 40.00

Work Assignment Type: Onsite

Work Schedule: Day Job

Location of Job: LENOIR MEM

Exempt From Overtime: Exempt: No

Qualified applicants will be considered without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, genetic information, disability, status as a protected veteran or political affiliation.