Reviews, analyzes, and interprets clinical documentation, seeking clarification from the physician when discrepancies exist. Effectively communicates with physicians and allied health personnel the need for comprehensive, accurate and timely clinical documentation.
Applies ICD-9 codes, ICD-10 codes, DRG codes, present on admission codes, patient status codes, and participating physician codes with an understanding of how each is used and the impact the accuracy of the data has on mortality rates, clinical quality, reimbursement, internal score cards and key quality indicators
Has an exhaustive understanding of the Official Coding Guidelines, Coding Clinic guidance, medical necessity and coverage determinations as indicated by the ability to complete records with a minimum of data quality review. Has responsibility to ensure the correct DRG prior to billing with the ability to defend the DRG assignment if questioned by an outside review agency.
Assists with DRG auditing and validation as needed for newer coders and for external coding audit review
Mentors more junior level staff and provides coding/clinical education when necessary ensuring that the entire coding staff develops the highest level of excellence
What Will You Need:
EDUCATION AND EXPERIENCE REQUIRED:
Experienced level with at least five years acute-care inpatient coding experience in a hospital setting
EDUCATION AND EXPERIENCE PREFERRED:
At least one-two years of coding education including formal education in anatomy, physiology and medical terminology.
Comprehensive experience with cases that require a more complex level of coding
LICENSURE, CERTIFICATION OR REGISTRATION REQUIRED:
RHIA, RHIT, or CCS certification or credential
The Senior Inpatient Coder is responsible for reviewing, analyzing and interpreting clinical documentation contained in the medical record applying appropriate ICD9, ICD-10CM, ICD-10PCS and DRG codes used for quality reporting and reimbursement purposes. The Senior Inpatient Coder provides a level of experience and expertise such that coding quality review is not needed prior to billing. The Senior Coder also uses years of experience and expertise to provide leadership within the coding section, mentoring others and providing assistance to management to maintain excellence in coding. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
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