Summary:
The Senior Coding Specialist reviews the clinical documentation to extract data and assign appropriate codes in accordance with the ICD-10-CM Official Guidelines for Coding and Reporting. Determines appropriate MS-DRG or APR-DRG assignment for optimal classification and accurate and compliant clinical reporting. Identifies and recommends physician queries when documentation in the chart is incomplete ambiguous or unclear. Maintains and meets HIS quality and productivity standards.

Responsibilities:

Reads the medical record identifying all treated diagnoses and procedures reporting the correct code(s) adhering to rules set forth in *Official Coding Guidelines for Coding and Reporting.* Ensures the medical record documentation supports the codes selected for the principal diagnosis secondary diagnoses complications co-morbid conditions procedures and discharge disposition. Abides by the *Standards of Ethical Coding* as set forth by the American Health Information Management Association. Understands clinical documentation to recognize when a query to the physician is required.

For inpatient coding enters coded/abstracted information into the 3M Encoder assigning the accurate MS-DRG or APR-DRG through use of the clinical analyzing functions used in the coding process. Adds Present On Admission (POA) indicator to diagnoses. Selects the physician performing procedures ensuring accuracy in the hospital*s billing system. Updates Clinical Documentation working DRG. Sends accounts to the coding validation software program upon which a validator reviews selected cases. Prioritizes high paying records to be completed per department policies. May perform concurrent coding for in-house patients requiring interim billing. Continually meets or exceeds the productivity standards set by departmental policies and national standards. Maintains average of 95% coding accuracy.

Follows-up on all bill holds physician queries validates requests and audit reviews to ensure timely billing and proper reimbursement. Acts as a resource to physicians and other staff on coding principals guidelines and DRG assignments and/or outpatient coding issues.

Refers coding billing and system questions to the Director of Coding or coding validator. Seeks supervisory assistance only after exhausting own resources by referencing appropriate coding publications and manuals. Assists coders and entry level coders as needed answering questions and providing guidance.

Keeps abreast of coding guidelines reimbursement and reporting requirements. Maintains certification requirements with CEU's and keeps credentials in good standing.

Maintains health information confidentiality by adhering to established organizational and departmental policies and procedures.

Performs related clerical and other duties as assigned.

Other information:

BASIC KNOWLEDGE:

Associate degree in health information technology (preferably with RHIT) and/or successful completion of coding certification program. Coding certification required from the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC). Familiarity and understanding of the content of the medical record. Trained in anatomy physiology and disease processes. Ability to recognize and understand clinical documentation pertinent for coding. Good writing skills to prepare physician queries. Must have computer skills to use an electronic medical record an encoder program e-mail and Microsoft Office products as necessary. Ability to do research on internet websites to clarify diseases and procedures. Ability to access and recognize appropriate electronic documents for coding.

EXPERIENCE:

3-5 years inpatient coding experience reading medical records in an acute care facility.

WORKING CONDITIONS:

After orientation at the hospital*s facilities work is performed at the employee*s residence in accordance with provisions of a telecommuting work agreement to which the employee has agreed as a condition of working in an off-campus location. The hospital*s normal office and central work location environment applies for assignments meetings and other requirements as determined by department management. Typically this type of work exists in a temperature controlled office environment and requires long periods of sitting to review medical records. Visual acuity to read large amounts of data ability to use hands with finger dexterity to enter data on a computer keyboard and to bend and stoop to file records. Ability to work under stressful conditions to maintain compliance with applicable standards.

INDEPENDENT ACTION:

Works independently and abides by the department*s policies procedures and practices. Refers specific complex problems to direct supervisor when clarification of the departmental policies and procedures are required.

SUPERVISORY RESPONSIBILITY:

None

Lifespan is an Equal Opportunity / Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race color religion sex national origin age ethnicity sexual orientation ancestry genetics gender identity or expression disability protected veteran or marital status. Lifespan is a VEVRAA Federal Contractor.

Location: Corporate Headquarters USA:RI:Providence

Work Type: Full Time

Shift: Shift 4

Union: Non-Union