St. Charles Health System

Compensation

Full Description

Pay range: $27.20 - $40.79 per hour, based on experience. This full-time position comes with a comprehensive benefits package that includes medical, dental, vision, a 403(b) retirement plan, and a generous Earned Time Off (ETO) program. ST. CHARLES HEALTH SYSTEM JOB DESCRIPTION TITLE: HB Coding Specialist III – Inpatient coder REPORTS TO POSITION: Coding Supervisor DEPARTMENT: Health Information Management DATE LAST REVIEWED: May 2024 OUR VISION: Creating America’s healthiest community, together OUR MISSION: In the spirit of love and compassion, better health, better care, better value OUR VALUES: Accountability, Caring and Teamwork DEPARTMENTAL SUMMARY: The Health Information Management Departments provide many services to our multi-hospital organization including prepping, scanning and indexing, physician deficiency analysis, release of information, medical record maintenance, facility and profee coding. POSITION OVERVIEW: The Hospital Coding Specialist III at St. Charles Health System is responsible for coding/abstracting inpatient records. This position does not directly manage other caregivers, however, may be asked to review and provide feedback on the work of other caregivers. ESSENTIAL FUNCTIONS AND DUTIES: Advanced skills in reading and interpreting documents contained in the medical record to identify and code all relevant ICD-10-CM diagnoses and ICD-10 PCS procedures by utilizing an encoder program, and following National and SCHS coding guidelines, Coding Clinic, and other appropriate coding references and tools to ensure proper code assignment. Abstracts medical record information in compliance with CMS requirements and SCHS abstracting procedures. Uses available tools to check entries for accuracy. This may include data for clinical studies and quality management activities. Selects principal diagnoses and procedures in accordance with coding and UHDDS standards, CMS requirements, and prospective payment systems. Ensures that correct MS DRG is assigned for proper hospital reimbursement. Ensures that APR DRG severity of illness and risk of mortality values are accurate for reporting purposes. Queries physicians for clarification when conflicting or ambiguous information is present by following appropriate SCHS procedures. Assigns Present on Admission (POA) indicator accurately for each diagnoses coded, per CMS requirements published in official ICD-CM coding guidelines, and if uncertain, query the physician. Accurately assigns discharge disposition code, paying particular attention to post-transfer program DRGs for proper hospital reimbursement. Plays an active role with the CDI (Clinical Documentation Improvement) team ensuring chart documentation meets the necessary requirements for accurate coding and reimbursement. Maintains productivity and quality standards. Supports the vision, mission, and values of the organization in all respects. Supports Lean principles of continuous improvement with energy and enthusiasm, functioning as a champion of change. Provides and maintains a safe environment for caregivers, patients, and guests. Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies, and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings. Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient, and accurate. May perform additional duties of similar complexity within the organization, as required or assigned. EDUCATION Required: High School diploma or GED. Graduate of an AHIMA Accredited Health Information Technology program or certification in a self-study course from AHIMA or AAPC. Preferred: N/A LICENSURE/CERTIFICATION/REGISTRATION: Required: Must possess a valid Registered Health Information Technician (RHIT) certification or one or more of the following: RHIA, CCA, CCS, CCS-P, CPC, COC, CPC-H. This position will require the caregiver to maintain required educational credits (CE) through AHIMA or AAPC. Preferred: Risk Adjustment Coding (microcredential) or AAPCs Certified Adjustment Coder (CRC). Maintains required education credits (CE) through AHIMA or AAPC. EXPERIENCE: Required: Three years of hospital coding experience. Preferred: Inpatient coding experience. Familiarity with 3M encoder. Familiarity with CAC (computer assisted coding). PERSONAL PROTECTIVE EQUIPMENT: Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely. ADDITIONAL POSITION INFORMATION: Skills: Position Specific: Knowledge of ICD-10 CM and PCS code assignment. Knowledge of MS DRG and APR DRG reimbursement methodology. Knowledge of Present on Admission “POA” assignment. Knowledge of CPT-4 code assignment. Knowledge of CCI and MN edits and APC grouping. Knowledge of modifier and revenue code assignment. Maintains professional knowledge by attending educational workshops, reviewing professional publications, participating in educational opportunities. Communication/Interpersonal: Demonstrates SCHS values of Accountability, Caring and Teamwork in every interaction. Must have excellent communication skills and ability to interact with a diverse population and professionally represent SCHS. Ability to effectively interact and communicate with all levels within SCHS and external customers/clients/potential employees. Strong team working and collaborative skills. Must have a positive attitude, ability to multi-task, pay close attention to details, and be able to act in a professional manner and demonstrate excellent public relations skills. Ability to work in a fast paced work environment with frequent interruptions, maintaining the highest level of confidentiality at all times. Ability to effectively reach consensus with a diverse population with differing needs. Organizational Ability to multi-task and work independently. Attention to detail. Excellent organizational skills, written and oral communication and customer service skills. Strong analytical, problem solving and decision-making skills. Language Skills: Read, write, speak, and understand English. Computer Skills: Intermediate ability and experience in computer applications, specifically electronic medical records system, and MS Office. Basic experience in computer applications necessary to record time, obtain work directions, and complete assigned CBL’s. PHYSICAL REQUIREMENTS: Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level. Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation. Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing. Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle. Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level. Exposure to Elemental Factors Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface. Blood-Borne Pathogen (BBP) Exposure Category No Risk for Exposure to BBP . Schedule Weekly Hours: 40 Caregiver Type: Regular Shift: First Shift (United States of America) Is Exempt Position? No Job Family: SPECIALIST HIM Scheduled Days of the Week: Monday-Friday Shift Start & End Time: Flexible between the hours of 6a - 6p St. Charles Health System is a private, nonprofit organization, dedicated to providing high-quality care and the latest in health care technology to the communities it serves. Headquartered in Bend, Ore., St. Charles is an integrated delivery system, with a strong focus on population health, that provides a full range of evidence-based health care services within a 32,000-square-mile area in Central and Eastern Oregon. The health system owns and operates a trauma level II, tertiary referral center in Bend, a trauma level III, type B rural hospital in Redmond, and trauma level IV critical access hospitals in both Prineville and Madras. As the largest employer in Central Oregon, St. Charles Health System and St. Charles Medical Group care for our communities in more than two dozen outpatient clinics and in more than 20 specialty areas of medicine. 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