Catholic Health Initiatives CODER II in HOUSTON, Texas
Review clinical documentation and diagnostic results to extract data and apply appropriate international classification
system (ICD-9. CM and/or ICD-10. CM/PCS) and CPT (Current Procedural Terminology) codes to multiple categories of
inpatients, ambulatory surgery and bedded outpatient records. Utilize advanced working knowledge of coding systems
and critical thinking skills in assigning and evaluating appropriateness of MS-DRGs, APR-DRGs, HAC (Hospital Acquired
Conditions) and POA (Present on Admission) conditions. Apply knowledge of official coding guidelines and other regulatory
guidelines. Query physicians to ensure appropriate documentation for accurate coding. Read and interprets multiple
healthcare providers’ documentation relevant to coding. Inpatient coding is performed for billing/reimbursement,
statistical purposes, internal and external data collection, research and regulatory compliance. Clinical and statistical data
is used by Quality Outcomes Management, research, DNV (Det Norske Veritas), Texas Health Care Information Council
(THCIC) and other internal and external entities.
- Translates the clinical care of the patient into a coded format for diagnoses, treatments and procedures on
acute inpatient, maternity, newborn, rehabilitation, ambulatory surgery, observation and emergency room
patients according to the appropriate international classification system (ICD-9. CM and/or ICD-10. CM) and/or
CPT (Current Procedural Terminology) for final billing and/or medical necessity checking, abstracting data when
required according to encounter type.
- Utilizes advanced coding expertise to identify, abstract, sequence and code principal and secondary
diagnoses and procedures, discharge disposition, MS-DRGs, APR-DRGs, POA and HAC conditions when
appropriate, to acute inpatient records and specialized records such as rehab and research
- Utilizes technical coding principles and APC reimbursement expertise to assign identify, abstract, sequence
and code (utilizing ICD-9. CM and/or ICD-10. CM and CPT-4. principal and secondary diagnoses and
procedures, and discharge disposition for day surgery and emergency room records according to Department
procedures and coding guidelines.
- Enters information into the medical necessity software for Medicare bedded outpatients to determine if tests
ordered are medically necessary based on the diagnoses given by the physician.
- Follows coding compliance policies, official coding guidelines, regulatory requirements and internal coding
guidelines affecting the coding process.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management
Association (AHIMA) and adheres to official coding guidelines.
- Adheres to all St. Luke’s policies, procedures, and standards, within budgetary specifications, including time
managements, supply management, productivity and accuracy of practice.
Supports department-based goals which contribute to the success of the organization.
Performs concurrent review and coding of in-house patients for the purpose of interim billing. Coordinates
work flow and facilitates handling of external and internal requests related to this function.
- Communicates with physicians in writing and/or verbally regarding clarification of clinical
- Additional responsibility may be assigned by location:
- Auditing and review of physician coding. Provide feedback and reporting results to the clinic leaders and
physician based on audit findings
Education and Licensure Required:
High School Diploma/GED
Certified Coding Specialist (CCS) –OR- Registered Health Information Technician (RHIT) –OR- Registered
Information Administrator (RHIA)
Physician Enterprise requirement: High School Diploma/equivalent plus graduation from medical billing school
- Three (3) years as a DRG coder in an acute care facility required
Minimum Knowledge, Skills, and Abilities:
Must have thorough knowledge of medical terminology, anatomy and physiology.
Must pass coding test administered by coding supervisor
Ability to use a personal computer for input, evaluation and specificity of diagnostic/procedural information
Ability to read and interpret health record documentation relevant to coding
Ability to code multiple categories of inpatient, ambulatory surgery and outpatient records across a multi-facility system
Applies knowledge of official coding guidelines and other regulatory guidelines while coding
Must use sound judgment when abstracting and sequencing diagnoses and procedures from the entire record (including
handwritten physician notes) and assigning the most accurate and specific code from the current International
Classification of Disease (ICD-9. CM, ICD-10. CM/PCS) and Current Procedural Terminology (CPT). Must be able to analyze
and interpret data and solve problems, work collaboratively with Coding Quality Coordinators and utilize appropriate
- Careful attention to detail is necessary while assigning ICD-9. CM and/or ICD-10. CM/PCS and CPT code numbers,
physician identification numbers and abstracting. Must identify physicians by recognizing their signatures in the medical
- Must meet established deadlines for processing work so that hospital cash flow will not be affected; this includes working
overtime as needed
Must Accurately capture all necessary data
Is able to make independent judgments on how to proceed with incomplete or ambiguous cases with minimal
- Must have the ability to work independently with little supervision, yet contribute to a team environment
Job Recruiter Select Job Field
Primary Location TEXAS-HOUSTON-ST LUKE'S ADMIN OFFICES STE 832
Daily Schedule FTE
Scheduled Hours per 2-week Pay Period 80
Weekends Required Occasional
Req ID: 2018-R0168397
We’re an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status.