HIM Coder - Certified (Remote)

Key Accountability

· Responsible for review, coding and abstracting of all outpatient charges for hospital records using the encoder or ICD-10-CM, CPT-4 and HCPCS books, into hospital computer system. Verifies all charges entered on the account.

· Performs deficiency verification for outpatient, clinic, ER and inpatient records verifying all have pertinent and complete documentation, lab reports, x-ray reports, etc. for all services ordered. Verifies orders for testing are complete with date of order, testing ordered and completed, diagnosis, and practitioner signature before coding.

· Responsible for assisting in HIM work queues for coding issues, claim edits and deficiencies.

· Adheres to official ICD-10-CM, CPT-4 and HCPCS coding and reporting guidelines.

· Adheres to Local and National Coverage Decisions as distributed by Medicare and/or Title XIX.

· Ensures completeness and accuracy of medical record documentation in accordance with accrediting and regulatory agency requirements.

· Analysis and review of charges and documentation to ensure accurate charge capture and billing compliance.

· Responsible for correctly abstracting data, i.e. disposition codes correct, date of service correct, place of service, service type correct, etc. when coding.

· Assists in the overflow activities of the department, performing backup coverage for other coders.

Key Accountability

· Answers and responds to incoming calls in a courteous and professional manner following the Standards of Behavior. 20%

Key Accountability

· Responsible to participate in completion of department and hospital goals.

· Responsible for attending mandatory in-services, department meetings and other in-

services applicable to the department.

· Actively participate in team-oriented decision-making process. Is a team player, willing to be flexible and open to other’s ideas.

· Focus portions of daily work towards high customer satisfaction. The goal of all employees is to meet or exceed our customer’s expectations 100% of the time.

· Develop a proactive mind set towards the job. Observes opportunities for improvement, formulates ideas, communicates those ideas with their supervisors and/or staff, carries out variations in work habits in continuous quality improvement.

Basic Clarke County Hospital (CCH) Performance Criteria

· Demonstrates Clarke County Hospital Standards of Behaviors as well as adheres to department and hospital policies and procedures and safety guidelines.

· Demonstrates ability to meet business needs of department with regular, reliable attendance.

· Employee maintains current licenses and/or certifications required for the position. Maintaining professional growth and development by attending education in-services as directed.

· Practices and reflects knowledge of HIPAA, DIA, DNV, OSHA and other federal/state regulatory agencies guiding healthcare.

· Completes all annual education and competency requirements within the calendar year.

· Is knowledgeable of hospital and department compliance requirements for federally funded healthcare programs (e.g. Medicare and Medicaid) regarding fraud, waste and abuse. Brings any questions or concerns regarding compliance to the immediate attention of hospital administrative staff. Takes appropriate action on concerns reported by department staff related to compliance.