Outpatient Coder 2

Miami, FL Full-Time Health Information Management

Summary

HIM Outpatient Coder 2 is responsible for coding and abstracting outpatient medical records, including outpatient Surgeries, GI Procedures and Cardiac Catheterizations. The Coder 2 is responsible for reviewing the clinical documentation contained in the patient health record to accurately assign and sequence ICD-9 and CPT codes for use in reimbursement and data collection. Able to transition to ICD-10-CM/PCS.

Responsibilities

Codes outpatient surgeries, including GI Procedures and Cardiac Catheterization procedures using ICD-9 or CPT codes as appropriate. Maintains a yearly average accuracy rate of 94% during internal and/or external Coding audits. Verifies patient information to identify any discrepancies and ensures that all codes and any other abstracted information is applied to the appropriate patient's encounter. While reviewing the record for coding purposes, serves as a quality reviewer and identifies any documents not belonging to the patient, or the correct patient's encounter. Ensures the accuracy when using the appropriate modifiers while coding outpatient's encounters. Assesses documentation and if necessary queries the physician for additional information when indicated to clarify a diagnosis, symptom or any reason for services provided. Makes sure all codes are utilized to reflect the care rendered to the patient which in return will ensure patient safety, accuracy of data retrieval and provides the organization with accurate reimbursement for the care provided to the patient. Evaluates to determine that data documented substantiates the diagnosis and treatment and is internally consistent as required by accreditation standards. Recognizes and reports unusual circumstances and/or information with possible risk factors to the Coding Associate Administrator or the Coding Director. Meets continuing education requirements established by American Health Information Management Association (AHIMA) and/or American Association of Professional Coders (AAPC) to maintain appropriate certification and competency in job skills and knowledge. Meets productivity standards according to AHIMA Guidelines depending on outpatient record type. Is actively involved in all ICD-10-CM/PCS education sessions provided by Jackson Health Systems. Shows competency according to education received. Adheres to the Standards of Excellence at all times, and respects the rights, privacy and property of others at all times including the confidentiality of information, according to Administrative Policies HIPAA Guidelines and all applicable laws and regulations. Demonstrates behaviors of service excellence and CARE values (Compassion, Accountability, Respect and Expertise). Performs other related duties as assigned.

Experience

Generally requires 3 to 5 years of related experience.

Education

High School diploma is required.

Skill

Ability to analyze, organize and prioritize work accurately while meeting multiple deadlines. Ability to communicate effectively in both oral and written form. Ability to handle difficult and stressful situations with critical thinking and professional composure. Ability to understand and follow instructions. Ability to exercise sound and independent judgment. Knowledge and skill in use of job appropriate technology and software applications.

Credentials

Employee hired AFTER June, 2015 must be credentialed with an HIM/Coding Credential and/or Certification by AHIMA or AAPC. AHIMA ICD10-CM-PCS Trainer preferred.