Medical Coder

Job description

Position Function: Under the direction of the Coding Manager, functions as a medical coder for the Health Information Management Department to review, retrieve, collect, and assign appropriate ICD-10-CM diagnoses codes and ICD-10-PCS or CPT codes for the purposes of compliance with regulations, data and statistical compilation, clinical research, clinical care analysis and optimal reimbursement.

Essential Functions and Responsibilities

Unit Based Essential Functions and Responsibilities

Core Values: Service, Integrity, Compassion
1.

Demonstrates service excellence and patient and family centered care by showing respect, honesty, fairness, and a positive attitude toward all customers.
2.

Maintains confidentiality.
3.

Demonstrates dependability, to include attendance and punctuality.
4.

Is accountable - takes initiative and ownership of issues.
5.

Displays a professional demeanor.

Represents hospital in a positive way.

Has a compassionate working relationship with patients and families.
6.

Assumes personal responsibility for 2-way communication.

Communicates and listens effectively with patients, families, coworkers, other departments, physicians/providers, and community.
7.

Supports coworkers, initiatives and a patient and family centered philosophy; pitches in; does own part and helps others.
8.

Works to continuously improve work environment/processes (Performance Improvement).

Demonstrates a patient and family centered focus when considering/developing improvement solutions.
9.

Represents willingness/enthusiasm to create, embrace and facilitate change.
10.

Develops self and others; supports a learning environment; leads by example.

Encourages patients and families to give feedback and suggestions for improvement.
11.

Develops working relationships critical to the organization including patients, families, coworkers, other departments, physicians/providers, and community.
12.

Encourage others by providing recognition and support.

Technical Excellence
1.

Thinks critically; utilizes sound judgment; promptly reports potential risks.
2.

Maintains state of art knowledge of area of specialty, healthcare trends and practice, and populations served.
3.

Maintains a level of computer literacy appropriate to their role.
4.

Meets and maintains current all unit specific and organizational skills/competencies, certifications/licensures, as required.
5.

Completes hospital-required reviews, e.g., HIPAA, safety, health screening, care concerns, and others as assigned.
6.

Adheres to National Patient Safety Goals.

Job Class Specifics
1.

Attends, unless excused, all departmental huddles, in-services, and educational programs to develop new skills and maintain competencies.
2.

Meets and maintains established productivity and quality standards for a total of 9 out of 12 months within the evaluation period.
3.

Completes an electronic daily productivity worksheet and submits it by the end of each workday.
4.

Plans and prioritizes workload at the beginning of shift and throughout shift in accordance with departmental goals for coding turnaround.
5.

Selects the most accurate DRG for each inpatient account, maintaining compliance based on approved coding guidelines and conventions.
6.

Reviews entire inpatient electronic health record to accurately code and sequence diagnoses and procedure codes according to ICD-10 CM/PCS Official Guidelines for Coding and Reporting and other regulatory guidelines with 95% accuracy or higher.
7.

Works cooperatively with the medical staff and other healthcare professionals in obtaining documentation to complete medical records and ensure optimal and accurate coding.

Communicates effectively with medical staff through use of electronic queries per established departmental policy.
8.

Reviews entire ambulatory surgery, observation, or outpatient electronic health record to accurately code and sequence diagnosis codes according to ICD-10-CM Official Guidelines for Coding and Reporting and to support medical necessity with 95% accuracy or higher.
9.

Assigns appropriate first-listed and secondary CPT/HCPCS and modifiers for outpatient procedures according to CPT and OCE/NCCI coding guidelines with 95% accuracy or higher.
10.

Reviews medication administration records and accurately posts infusion administration charges for observation, outpatient oncology and infusion service accounts.
11.

Reviews interventional cardiology procedure logs and documentation to verify, correct and update procedure or charge codes to ensure accurate coding and charging of procedures, devices, implants, and supplies.
12.

Abstracts patient data, including discharge status, consulting providers, admitting, and attending provider, and surgeon from electronic health record to appropriately complete Epic ADT Information screen prior to completing an account for billing and claims submission for inpatient, ambulatory surgery, or outpatient visit account with 95% accuracy.
13.

Reviews professional journals, newsletters, and educational assignments in a timely fashion to keep up to date on current coding guidelines.

General Requirements

The following requirements are expected of all employees:

Core Values: Integrity, Compassion, Excellence, Service
Annual Health Screening with Infection Control and Blood Borne Pathogens Education Safety Awareness: Hospital Fire, Safety, and Disaster procedures
Confidentiality: Maintains employee and patient confidentiality.

Attendance: Regular attendance is an essential function of the position Leadership Standards:
Character: Attitude, Integrity, Role Modeling
Job Performance: Results orientation, Customer focus, Decision making, Awareness
Interpersonal Skills: Communication, Relationship-building, Team player, Celebration
Innovation: Breakthrough Thinking, Knowledge-Building/Sharing, Coaching/Empowering, System Vision & Management

Physical and Mental Requirements: Physical Standards and Abilities - Classified as sedentary work by the Dictionary of Occupational Titles: May exert up to ten pounds of force occasionally and/or an insignificant amount of force frequently or constantly in order to lift, carry, push, pull or otherwise move objects.

Work involves sitting most of the time on a hard or cushioned chair.

Manual dexterity adequate for utilizing a keyboard and computer mouse.

Ability to adapt to simultaneous, multiple and varied stimuli.

Auditory acuity adequate for hearing telephone or virtual conversations, normal voice tones when not facing the individual, overhead pages, etc.
Mental Demands - Ability to communicate in both written and verbal form and relate to staff and others.

Ability to speak, read and write the English language.

Ability to efficiently and effectively handle multiple demands simultaneously as a result of working under the pressure of deadlines.

Working Environment: Work is performed remotely in an approved, designated home-based workspace.

Reporting Structure:
Formal Reporting and Chain of Command - Reports to the Coding Manager.

In his/her absence, reports to Senior Director of Health Information Management.
Informal Reporting and Relationships - Establishes and maintains working relationships within the department, with other departments, medical staff and with the public.

Disclaimer: These essential job functions are requirements of the position, which must be performed either with or without reasonable accommodation.

The essential job function list is intended to be a guide rather than a limitation.

The Chambersburg Hospital possesses the right to add new responsibilities to the list as business demands dictate.

Some of the essential job functions may exclude individuals who pose a direct threat/significant risk to the health and safety of themselves or others.

By identifying essential job functions, we are in no way stating or implying that these required tasks are the only activities that are to be performed by the employee occupying this position.

In addition, employees will also be expected to follow any other job-related instructions and to perform any other job-related duties that are included in the job description.

The preceding requirements represent only the minimum acceptable levels of knowledge, skills, and/or abilities that a job incumbent must possess; to perform the job successfully, the incumbent will possess additional aptitudes to perform the other duties that the job description entails.

Qualifications and Standards

Education: Formal Education and Training -
- Certified Coding Specialist (CCS) with at least one year of acute care coding experience.
- OR a Registered Health Information Administrator (RHIA) with at least one year of acute care coding experience.
- OR a Registered Health Information Technician (RHIT) with at least one year of acute care coding experience.
- OR a Certified Coding Associate (CCA) with at least two years of acute care coding experience.
- OR a Certified Professional Coder/Hospital (CPCH) or Certified Professional Coder (CPC) with at least two years of acute care coding experience.
- OR a Bachelor's Degree with at least one year of acute care coding experience.
- OR an Associate Degree with at least one year of acute care coding experience.
- OR a High School Diploma with at least three years of acute care coding experience.
- Other formal training of ICD-10-CM/PCS and CPT coding; knowledge of medical terminology, anatomy, and physiology; basic computer skills and coding experience.

Experience: Experience applying customer service behaviors and communication skills required.

See above Education section for requirements.

Certifications/Licensure: See above Education section for requirements.

**Quality of Life**

Franklin County, named after Benjamin Franklin, was officially formed in 1784.

One of its two main towns, the borough of Chambersburg, lies 13 miles north of Maryland and is known for its green, safe environment.

In the southern part of Franklin County, the borough of Waynesboro sits just two miles north of the Mason-Dixon Line and is known for its rich industrial history.

Franklin County is in the heart of Central Pennsylvania, where you'll find mountains, lakes and a picturesque countryside coupled with theater, music, skiing, hunting, fishing and much more.

We're in the heart of America's fruit orchards, so peaches, apples and lots of other local produce are available close by.

The area features local wineries and breweries, along with a vibrant arts scene at the historic Capitol Theatre and Totem Pole Playhouse.

Franklin County merges the best of small-town friendliness with easy access to metropolitan areas.

(Patient population: 154,000)
WellSpan Health is an Equal Opportunity Employer.

It is the policy and intention of the System to maintain consistent and equal treatment toward applicants and employees of all job classifications without regard to age, sex, race, color, religion, sexual orientation, gender identity, transgender status, national origin, ancestry, veteran status, disability, or any other legally protected characteristic.

Required Skill Profession

Other General