Coder Analyst Inpatient Health Information

Facility:      Administrative Regional Training Cntr

Shift: Shift 1

Status:     Full Time      FTE: 1.000000

Bargaining Unit:     ACE Associates

Exempt from Overtime:     Exempt: No

Work Schedule:  Days

Hours:         

7-3 Mon-Fri flexible start end times (manager approved) 

Summary:

Codes primarily acute hospital inpatient, SNF, Rehab, for the purpose of accurate reimbursement, research and compliance with federal regulations.   Coding of Ambulatory, ER / Urgent Care, Interventional Radiology and same day surgery records is performed on an as needed basis.  Diagnoses and procedures are coded through review of the entire medical record, utilizing International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) and Current Procedure Terminology (CPT) classifications.  Queries physician for further clarification when there is uncertainty in the documentation of the medical record.  Analyzes and reviews records for completeness. Actively participates as a member of the Clinical Documentation Improvement Team (CDI Team) as outlined in this document.

Responsibilities:

EDUCATION  

• B.S. in Health Information Management or AAS in Health Information Technology or
• Certification as an RHIA or RHIT.  Certified Coding Specialist (CCS) is preferred.  Would also consider an RHIA or RHIT eligible candidate if enrolled in an HIT or HIM program and candidate has completed coding, medical terminology, anatomy & physiology;
• Experienced coder with the Certified Coder Specialist (CCS) credentials would also be considered
• Successful certification within one (1) year of date of hire or graduation, whichever is later (AHIMA)
• Candidates are required to take and successfully pass a Catholic Health (CH) coding test
• Maintains credentials by meeting AHIMA continuing education requirements
• CDI Team training and participation in CDI Team meetings and activities

EXPERIENCE

• Six (6) months coding experience in an acute care facility is preferred 

KNOWLEDGE, SKILL AND ABILITY 

• Thorough knowledge of ICD-10-CM and CPT coding systems, medical terminology, anatomy and physiology
• Partner with and across Teams.  Demonstrated ability to work closely with CH associates, medical staff, department managers, CDI Specialists and Finance
• Superior written and interpersonal communication skills
• Drive performance.  Ambitious, takes prompt action for priorities, addresses challenges & opportunities.  Possess skills related to organization and prioritization.  Is action oriented
• Demonstrated proficiency with computers, software, hardware and technological advances
• Problem Solving:  Includes appropriate staff in problem solving, defining, and prioritizing
• Excellent analytical skills
• Mobilizer.  Sets goals/expectations.  Ability to meet deadlines consistently and generate reports
• Change Driver.  Welcomes improvement, open to new ideas of others, helps others embrace change and accepts suggestions for change from other team members.  Embraces creative thinking, generates creative solutions
• Ability to read medical record documents and utilize computer to enter diagnoses, procedures and patient data throughout the day
• Ability and knowledge to review CDI worksheet and utilize (if appropriate) to code chart and/or query physician

WORKING CONDITIONS 

• Primary work is sedentary with majority of time spent sitting
• Frequent repetitive action of using computer keyboard
• Individual works in an office setting utilizing medical records, computers and various software and reference books to assign codes for accurate reimbursement
• Travel is required for float positions
• NYS Drivers license and transportation is required.  Travel between facilities to assist with coding at other sites
• Normal heat, light space, and safe working environment; typical of most office jobs