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PDS Tech Inc Senior HIM Coder - Inpatient in Tyler, Texas

Health Information Management Coder Senior- Inpatient

Position Summary:

Completion of Accredited Baccalaureate Health Informatics or Health Information Management or an AHIMA approved Coding Certificate Program, preferred.

• Strong written and verbal communication skills.

• Able to work independently in a remote setting, with little supervision.

• Experience Three (3) to five (5) years of Inpatient coding experience in an acute care setting. Licenses, Registrations, or Certifications Registered Health Information Administrator (RHIA) (AHIMA)

• Registered Health Information Technician (RHIT) (AHIMA)

• Certified Coding Specialist (CCS) (AHIMA)

• Certified Coding Associate (CCA) (AHIMA)

Responsible for maintaining current and high-quality ICD-10-CM/PCS coding for all Inpatient diagnoses and procedural occurrences, through the review of clinical documentation and diagnostic results, with a consistent coding accuracy rate of 95% or better. Coder will accurately abstract data into all appropriate company’s electronic medical record systems, verifying accurate patient dispositions and physician data, following the Official ICD-10-CM and ICD-10-PCS Guidelines for Coding and Reporting. Inpatient coding is applicable towards all regional Inpatient encounters. Coder will work collaboratively with various company’s HIM and Clinical Documentation Specialists to ensure accurate and complete physician documentation to support accurate billing and reduce denials. Coder will also assist in other areas of the department, as requested by leadership. Coder will report directly to their Regional Coding Manager, with additional leadership from the Director of Coding Operations and System HIM Director.

Major Responsibilities:

• Assign codes for diagnoses, treatments, and procedures according to the ICD-10-CM/PCS Official Guidelines for Coding and Reporting through review of coding critical documentation, to generate appropriate MS/APR DRG.

• Extracts and abstracts required information from source documentation, to be entered into appropriate company’s electronic medical record system.

• Validates admit orders and discharge dispositions.

• Works from assigned coding queue, completing and re-assigning accounts correctly.

• Manages accounts on ABS Hold, finalizing accounts when corrections have been made, in a timely manner.

• Meets or exceeds an accuracy rate of 95%.

• Meets or exceeds the designated company’s Productivity standard per chart type.

• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).

• Assists in implementing solutions to reduce backend-errors.

• Identifies and appropriately reports all hospital-acquired conditions (HAC).

• Expertly queries providers for missing or unclear documentation, by working with the HIM department and Clinical Documentation Improvement Specialists.

• Participates in both internal and external audit discussions.

• All other work duties as assigned by Manager.

Education/Skills High school Diploma or GED

All qualified applicants will receive consideration for employment without regard to race, color, sex, sexual orientation, gender identity, religion, national origin, disability, veteran status, age, marital status, pregnancy, genetic information, or other legally protected status.

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