CODER - Health Information Services

The Health Information Services Coder performs all inpatient and outpatient coding utilizing ICD-9-CM and CPT codes along with assuming all Tumor Board and Tumor Registry functions.
Assigns ICD-9-CM and CPT codes where applicable to all inpatient, outpatient, emergency room, and mammography records, following coding guidelines, to obtain optimal reimbursement on a daily basis.
Accuracy must be a minimum of 90%.
Utilizes the QuadraMEd coding system to access codes, assign them, and perform quality checks on all records.
Groups each inpatient record in the encoder system to obtain a DRG.
Enters codes in correct sequence to be put into the Precision Alternative system to be accessible to the Business Office.
Remains up-to-date on coding issues and changes.
Performs all Tumor Registry functions as required by the Pennsylvania State Tumor Registry, including tracking all cancer cases, maintaining a log in the computer system, completing Registry abstracts and sending monthly batches of to the State. Performs all functions pertaining to Tumor Board held at the hospital every other week. (This includes preparing the cases, educating student physicians, notifying physicians of the meeting, having the room arranged with the appropriate equipment, taking minutes during the meeting, typing them and distributing them as necessary).
Maintains a productivity chart and patient care log turned in monthly to the manager. Performs basic abstracting function on all records as specified in procedure.
Performs quality check on other coder's work as specified in procedure. Performs compliance audits on high risk coding areas.
Maintains confidentiality of all patient information.
Edits records as necessary for changes in insurance classes, physician requests, etc.
Works closely with the medical staff, Business Office, Utilization Review (KePro) and Medisgroups to assist and educate them in coding practices.
Works with MIS to have yearly updates integrated into the QuadraMed system. Works with students in the Health Information field when on internships.
Assists with coverage in the department when needed.
Reports any compliance related matter identified to the HIS Manager or Compliance Officer.
Attends seminars beneficial to coding guidelines and changes when available.
Works with the Manager and other coder on any coding issues and quality checks.
Assists with any other coding related activities.
Job Requirements

Must have completed coding certification program, with strong knowledge of Anatomy & Physiology.
IP coding experience preferred.
Must have inpatient hospital coding experience and have or be eligible for CCS or CPC credentials.
Be a Certified Coding Specialist (CCS) certification or within a year.
Registered Health Information (RHIT).
Registered Health Information Administrator (RHIA) or certified Physician Coder (CPC).
CPR within 90 days of hire.


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