Coder II

Overview

The HIM Coding Specialist II is required to have a full understanding and active participation in fulfilling the mission, vision and values of San Gabriel Valley Medical Center.  The employee shall support San Gabriel Valley Medical Center’s strategic plan and the goals and direction of the department Performance Improvement Plan (PIP).

The HIM Coding Specialist II is required to ensure that all patient records are coded within the bill-hold limits (4 days).  HIM Coding Specialist II is further responsible to ensure that all charts pass the SMART cycle and are adjusted as needed.  The HIM Coding Specialist II must have a comprehensive knowledge of ICD-10-CM, ICD-10 PCS, CPT conventions in accordance with Official Guidelines for Coding and Reporting.  The HIM Coding Specialist II is responsible for abstracting data into Evident/Thrive system using 3M encoder.  Furthermore, the HIM Coding Specialist II will work internally and externally with coding staff, HIM director and outside auditors and consultants to ensure the efficiency and quality of coding.  The HIM Coding Specialist II must at all times safeguard and protect the patient’s right to privacy by ensuring that only authorized individuals have access to the patient’s medical information and that all releases of information are in compliance with the request, authorization, company policy and HIPAA regulations.  

Responsibilities

DUTIES AND RESPONSIBILITIES:

• Accurately reviews all records that are flagged by SMART and other reviews as required.
• Ensures that all charts are coded within their bill hold limits.
• Works with outside auditors and consultants ensuring the quality of coding within the department.
• Reviews all charts that may be in questions in regards to billing and coding.
• Replies to external auditor regarding coding issues within 7-14 days.
• Compiles and maintains productivity reports on all coders.
• Educates and trains coding staff on an as needed basis.
• Accurately reviews all charts for diseases and procedures performed and assign appropriate ICD-9-CM and CPT codes according to guidelines.
• Accurately enters appropriate diagnoses and operative codes into the MIRA coding system computer.
• Code four (4) inpatient or eight (8) outpatient charts within one (1) hour.
• Works with endcoder optimizer feature to produce principal diagnosis scenarios for attending physician review according to department practice.
• Accurately codes and abstracts short stay surgeries and ER charts onto the outpatient abstract.
• Accurately codes outpatient referred cases and clinic visits onto the diagnosis verification screen.
• Works with case managers to obtain concurrent information when deemed necessary.
• Performs concurrent coding on inpatient records selected by the business office.
• Serve as an accurate resource to physicians and hospital personnel regarding assignment of principal diagnosis, sequencing of diagnoses and DRG assignment.
• Reviews OSHPD reports weekly and makes appropriate corrections.
• Works with HIM Director to complete evaluations for other coders within the department.

The above statements reflect the essential functions considered necessary to describe the principle content of the job. They are not intended to be a complete statement of all work requirements or duties that may be inherent in the job.

The following job accountabilities are non-essential and may be reassigned:

• Runs inpatient abstracts through the 3M encoder for DRG assignment.

• Prepares coding summary sheet for the chart.

• Does data searches for retrieval of information from the indices.

• Bar code all charts.

• Performs other duties as assigned.

Qualifications

EDUCATION, EXPERIENCE, TRAINING:

Experience: A minimum of four years coding experience in a hospital Health Information Management Department.

Education: High School Diploma or equivalent

Specialized Training: Must have good communication skills, must be able to read and write English, must be computer literate, ability to use tact and diplomacy when interacting with the staff and customers. 

Licenses/Certifications

• Certified Coding Assistant or Certified Coding Specialist credentials from AHIMA
• A minimum score on the AHMC Coding Examination of 95%
• RHIT, RHIA, or CCS.