Clinical Document Coding Specialist-HIM Dept

Clinical Document Coding Specialist-HIM Dept

Requisition Number: 3985
Job Title: Clinical Document Coding Specialist-HIM Dept
Department: UUH CST 17E HEALTH INFO DEPT
Reg / Temp: Regular
Employment Type: Full Time
Shift: Days
Work Schedule: Mon-Fri
Location: UNIVERSITY HOSPITAL - 50 NORTH MEDICAL DRIVE
City: SALT LAKE CITY
State: UTAH

Job Description:
: As a patient-focused organization, the University of Utah Health Sciences exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. The Health Sciences Center seeks faculty and staff that are committed to the values of compassion, collaboration, innovation, responsibility, diversity, integrity, quality and trust that are integral to our mission.

Position Summary:

This position is part of an interdisciplinary team and it is accountable for the integration and coordination of decentralized concurrent coding. This position will work directly on their assigned unit.
This position has the authority to make decisions to optimize reimbursement within State and Federal laws. If assigned lead worker status, the incumbent is authorized to schedule, direct, and oversee the work of Health Information Coders and other subordinate department personnel.

The incumbent must abide by Hospital, State, and Federal coding guidelines established by JCAHO, American Hospital Coding Association, and Medicare/Medicaid, etc

Essential Functions:

- Abstracts information from in-patient interim, discharge and out-patient medical records and enters the information into the appropriate database.
- Participates on the interdisciplinary team as a documentation expert on the inpatient units. Makes formal recommendations to the team for documentation improvement opportunities.
- Provides monthly, quarterly, and annual statistics reflecting effectiveness of the Clinical Documentation Improvement Program in coordination with the Clinical Documentation Improvement Nurse Specialist. Makes recommendations for process improvement based on empirical data evaluation. Reports trends in a timely manner to senior Leadership and providers.
- Assigns ICD-9-CM, CPT, ASC, APC, HCPCS, APRDRG and/or DRG's (Diagnostic related grouping) codes to patient diagnoses and procedures in real time as clinical charting is completed.
- Aides Physicians, Nurses and other clinical staff in summarizing and documenting the demographic and clinical patient information accurately and appropriately.
- Analyzes patient chart information for accuracy and completeness; clarifies vague or incomplete diagnostic and/or procedural information with physicians and other clinical staff when necessary to insure the use of the appropriate DRG's and or ICD-9-CM codes.
- Educates and advise the clinical staff on the scope of various DRG's and ICD-9-CM codes when requested to aid in the development of patient care plans.
- Rounds frequently on the inpatient units and audits initial coding entered by clinical staff.
- Seek opportunities for the hospital to utilize concurrent coding where ever feasible to allow for a more efficient use of the hospitals resources and increase the quality and accuracy of the coding and documentation of all of the facilities medical record.
- Researches and resolves inquiries from insurance companies, physicians and patients regarding charge and coding verification.
- Completes computer-generated interfaces to assure that all coding is accurately reported to the billing department.
- Tracks missing charges and work with billing companies to resolve coding and billing issues.
- Provides education to staff or providers regarding appropriate documentation and coding guidelines.
- May round concurrently on the inpatient units and code initially for a working DRG and subsequently for a final discharge DRG.

Knowledge / Skills / Abilities:

- Comprehensive understanding of the prospective payment system and the hospitals revenue cycle.
- Ability to maintain coding certification through continuing education.
- Demonstrated human relations and effective communication skills courses; excellent interpersonal skills and strong team player.
- Good computer skills and experience with the M.S. Office suite especially; Word, Excel & PowerPoint
- Ability to accurately code information when available documentation is vague or ambiguous; presenting that information to the interdisciplinary team.
- Ability to identifying computer problems and working with computer technicians to make necessary repairs; and coordinating with the billing office to identify unbilled accounts and locating or generating the coding required receiving reimbursement.
- Ability to resolve questions or requests from various entities that involve researching and verifying coding in patient records.

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Qualifications:
Required:
- Bachelor's degree in related area or equivalency.
- Four years of inpatient medical coding experience.
- Must have experience with medical coding applications, preferably HDM.
- A minimum of one AHIMA credential either the; RHIT, RHIA and or the CCS.
- Completion of courses in medical terminology, anatomy, physiology.