Description:
Interprets clinical documentation/records of basic outpatient cases to ensure all diagnoses and procedures are documented and coded.
Requisition Type: Business Support
Job Schedule: Full time
Job Shift: Day
Responsibilities:
A. Interprets clinical documentation/records to ensure all diagnosis and procedure documentation is coded.
B. Applies regulatory and facility guidelines while coding.
C. Code clinical documentation with an accuracy rate consistent with the hospital quality program.
Abstract clinical information from the medical record into the clinical information system with an accuracy rate consistent with the hospital abstracting quality program.  The inpatient and outpatient abstracting policy should be referenced for specific on TCH abstracting practices.
Documentation
A. Interprets health record content to ensure that all diagnoses and procedures assigned are supported by physician documentation.
Productivity
A. Coder will code and abstract medical records at a productivity rate that is consistent with the hospital productivity program.
Participates in continued quality improvement opportunities
Other duties as assigned
Qualifications:
KNOWLEDGE AND SKILLS:
EDUCATION: RHIA, RHIT, CCS, CPC-H, or CCA with 2 yrs. Hospital coding experience strongly preferred.   Skills assessment required determining competency level of coding skills and outcome determines placement in intermediate to advance level.
YEARS OF EXPERIENCE: 2 yrs. preferred.
REQUIRED SKILLS AND KNOWLEDGE:
Criteria:
Skills*:
Coder Associate:
Basic outpatient cases with simple diagnoses and procedures.
• Outpatient diagnostic testing.
Coder Senior:
Interprets clinical documentation/records of complex outpatient and/or basic inpatient cases to ensure all diagnoses and procedures are documented and coded.
Same Day Surgery
Endoscopy
Cardiac Cath
Interventional Radiology
Inpatient
Coder Lead:
Interprets clinical documentation/records of complex outpatient and/or complex inpatient cases to ensure all diagnoses and procedures are documented and coded.
Same Day Surgery
Endoscopy
Cardiac Cath
Interventional Radiology
Complex Inpatient Procedures
Education:
Coder Associate:
Successful completion of some coursework or formal education in:
ICD-10-CM, disease process and medical terminology.
Coder Senior:
Successful completion of coursework or formal education in:
ICD-10-CM, ICD-10-PCS, CPT, disease process and medical terminology
Coder Lead:
Successful completion of advanced coursework or formal education in:
ICD-10-CM, ICD-10-PCS, CPT, disease process and medical terminology
*Each increase in levels assumes the ability to code at the previous skill level.
CERTIFICATIONS & CREDENTIALS:
The following certifications are preferred:
• Registered Health Information Administrator (RHIA)
• Registered Health Information Technician (RHIT)
• Certified Coding Specialist (CCS)
• Certified Coding Associate (CCA)
• Certified Professional Coder - Hospital (CPCH)
• Applicable associate or bachelor's degree