Inpatient Coder Job at Good Shepherd Rehabilitation, Allentown, PA

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  • Good Shepherd Rehabilitation
  • Allentown, PA

Job Description

*This position is remote, and the candidate must reside in Pennsylvania or New Jersey*

JOB SUMMARY

  • Reviews patient records, assigns diagnostic and procedural codes, performs related functions and participates in Performance Improvement activities.

ESSENTIAL FUNCTIONS

DIAGNOSTIC CODING OF ALL MEDICAL RECORDS REPORTED ON PATIENT BILLS

  • By coding all diagnoses, treatments, and procedures according to the appropriate classification system for the category of patient encounter
  • By accurately coding all inpatient records in accordance with ICD-10 CM/PCS coding rules and guidelines in a timely manner with a 95% accuracy rate
  • By following approved coding conventions, assigns diagnostic and procedural codes to inpatient records
  • Reviews AHA Coding Clinic and demonstrates the ability to accurately apply new coding guidelines.
  • Researches new diagnostic and procedure codes as required performing the coding function.
  • Informs coding supervisor of trends and opportunities for improvement in clinical documentation.
  • Works collaboratively with other coders.
  • Adheres to the American Health Information Management’s Code of Ethics.

LOCATES MEDICAL RECORDS THAT REQUIRE CODE ASSIGNMENT

  • By searching master patient index; identifying location of existing patient records and obtaining the documentation required for code assignment.

MAINTAINS MEDICAL RECORDS OPERATIONS

  • By following policies and procedures; reporting needed change

RESOLVES MEDICAL RECORD DISCREPANCIES

  • By acting as a resource to other staff on coding issues
  • By assisting the physicians with documentation improvement via the diagnostic query form
  • By collecting and analyzing information

MAINTAINS HISTORICAL REFERENCE

  • By abstraction and data entry of all inpatient records into the Good Shepherd Hospital computer system for clinical and financial purposes
  • By abstracting and coding clinical data, such as diseases, procedures, using standard classification systems.
  • By providing DRG/CMG forecasting information to Nurse Liaison as needed.
  • By accurately assigning the correct principal diagnosis on LTCH and rehab accounts.
  • By performing weekly/bi-weekly concurrent chart reviews for any potential DRG/CMG changes during the patient stay.
  • By coding all discharged charts timely and accurately

PROVIDES MEDICAL RECORD INFORMATION

  • By providing codes for billing and answers questions from hospital staff
  • By assisting physicians and other direct patient care professionals in questions regarding level of detail for diagnostic entries, according to the organization’s guidelines

MAINTAINS THE STABILITY AND REPUTATION OF THE HOSPITAL

  • By complying with legal requirements.

QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education

  • High School Diploma required
  • Completion of the AHIMA independent study program preferred

Work Experience

  • 2-4 years of inpatient coding experience utilizing ICD-9-CM and/or ICD-10-CM/PCS required

Licenses / Certifications

  • RHIA, RHIT, CCS, CPC, active member in AHIMA preferred

Job Tags

Work experience placement,

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