Kristin
Contributor
JOB SUMMARY:
Reviews clinical documentation and diagnostic results as appropriate to extract abstract data and apply appropriate ICD-9-CM/ICD-10-CM/PCS1 and CPT 4 codes for billing internal reimbursement, external reporting, research, regulatory compliance, medical necessity, CCI, NCCI and other regulatory edits. Code and abstract medical records of moderate to high complexity within the CHS Primary Enterprise acute care facilities.
ESSENTIAL FUNCTIONS:
1. Reviews moderate to high complexity medical records to identify the appropriate principal diagnosis and procedure codes and all other appropriate secondary diagnoses and procedure codes and assign Present on Admission indicators, Hospital Acquired Conditions and Core Measures for all diagnosis codes.
2. Facilitates appropriate MSDRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines.
3. Reviews charges and Evaluation and Management levels.
4. Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an on-site or remote setting
5. Demonstrates proficiency with Microsoft Office Applications and in using required computer systems with minimal assistance
6. Abstracts coded data and other pertinent fields in the hospital electronic health record. Ensures the accuracy of data input.
7. Meets established quality and productivity standards.
8. Stay abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding.
9. Attends internal and external educational seminars to satisfy continuing education requirements and maintain certification.
10. Supports and contributes to the Patient-Centered Care Philosophy by understanding that every staff member is a Caregiver, whose role is to meet the needs of each patient.
MARGINAL FUNCTIONS:
1. Performs other duties as assigned.
PHYSICAL REQUIREMENTS: Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment.
EDUCATION, EXPERIENCE AND CERTIFICATIONS: High School Diploma or GED required; Bachelor’s Degree preferred. Advanced knowledge in Medical Terminology, Anatomy and Physiology and Pharmacology. Two years coding experience in acute care setting. Current RHIT, RHIA, CPC-H, CIC or CCS required plus a passing score on the CHS Coding test.
Please apply at https://careers.carolinashealthcare.org/ keyword Clinical Coder.
Reviews clinical documentation and diagnostic results as appropriate to extract abstract data and apply appropriate ICD-9-CM/ICD-10-CM/PCS1 and CPT 4 codes for billing internal reimbursement, external reporting, research, regulatory compliance, medical necessity, CCI, NCCI and other regulatory edits. Code and abstract medical records of moderate to high complexity within the CHS Primary Enterprise acute care facilities.
ESSENTIAL FUNCTIONS:
1. Reviews moderate to high complexity medical records to identify the appropriate principal diagnosis and procedure codes and all other appropriate secondary diagnoses and procedure codes and assign Present on Admission indicators, Hospital Acquired Conditions and Core Measures for all diagnosis codes.
2. Facilitates appropriate MSDRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines.
3. Reviews charges and Evaluation and Management levels.
4. Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an on-site or remote setting
5. Demonstrates proficiency with Microsoft Office Applications and in using required computer systems with minimal assistance
6. Abstracts coded data and other pertinent fields in the hospital electronic health record. Ensures the accuracy of data input.
7. Meets established quality and productivity standards.
8. Stay abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding.
9. Attends internal and external educational seminars to satisfy continuing education requirements and maintain certification.
10. Supports and contributes to the Patient-Centered Care Philosophy by understanding that every staff member is a Caregiver, whose role is to meet the needs of each patient.
MARGINAL FUNCTIONS:
1. Performs other duties as assigned.
PHYSICAL REQUIREMENTS: Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment.
EDUCATION, EXPERIENCE AND CERTIFICATIONS: High School Diploma or GED required; Bachelor’s Degree preferred. Advanced knowledge in Medical Terminology, Anatomy and Physiology and Pharmacology. Two years coding experience in acute care setting. Current RHIT, RHIA, CPC-H, CIC or CCS required plus a passing score on the CHS Coding test.
Please apply at https://careers.carolinashealthcare.org/ keyword Clinical Coder.
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