Medical Records Coder and Abstractor II

Job Description

Job Overview: Reviews and interprets clinical documentation to assign accurate and complete codes, modifiers, MSDRG's, APR-DRG's, SOI, ROM, POA indicators, discharge dispositions and any other clinical data elements required for appropriate reimbursement. Understands and applies reimbursement processes under federal compliance guidelines. Abstracts demographic and clinical data into hospital health information system(s) such as HDM, Epic, or other currently in use. Performs and responds to data quality checks and payer/claims issues. One may specialize in one or more of the standard functions. Specific assignments will vary from day to day based on the needs of the department. Job Requirements: Currently enrolled in an approved program for specific field of study in Within six months of hire, RHIT/RHIA and/or CCS Continuing education pursued in accord with requirements of the accrediting bodies CPC/CCA may be substituted at the hiring manager's discretion Proficiency in ICD and CPT coding DRG's MSDRG's POA indicators Post-acute transfer rules Disposition status Disease process and treatment Anatomy and medical terminology Clinical documentation requirements AHIMA Experience in a related field Job Responsibilities: Reviews and interprets clinical documentation to assign accurate and complete codes, modifiers, MSDRG's, POA indicators, discharge dispositions, and other data elements required for appropriate reimbursement, meeting established quality and productivity standards within 3 days of visit/discharge. Meets stated metrics for on-time completion. Collaborates effectively with associate departments as follows, but not limited to: Performs and responds to data quality checks and payer/claims issues with Billing and Denials teams. Works closely with CDMP toward complete documentation for most descriptive coding and DRG , APR-DRG, SOI, and ROM assignment. Obtains final disposition status from Care Coordination. Supports clinical specialty work teams (i.e. OB and Cardiac Surgery) Abstracts demographic and clinical data into hospital health data management systems. Participates in audits, training of new employees, education, project teams, etc. as needed. Other Job-Related Information: Working Conditions: Climbing - Rarely Concentrating - Consistently Continuous Learning - Consistently Hearing: Conversation - Frequently Hearing: Other Sounds - Frequently Interpersonal Communication - Consistently Kneeling - Rarely Lifting Apply Job!