Catholic Health Initiatives CODER II in HOUSTON, Texas

CODER II

Description

POSITION SUMMARY

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.

POSITION RESPONSIBILITIES

  1. 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.

  1. 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

  1. 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.

  1. 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.

  1. Follows coding compliance policies, official coding guidelines, regulatory requirements and internal coding

guidelines affecting the coding process.

  1. Abides by the Standards of Ethical Coding as set forth by the American Health Information Management

Association (AHIMA) and adheres to official coding guidelines.

  1. Adheres to all St. Luke’s policies, procedures, and standards, within budgetary specifications, including time

managements, supply management, productivity and accuracy of practice.

  1. Supports department-based goals which contribute to the success of the organization.

  2. 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.

  1. Communicates with physicians in writing and/or verbally regarding clarification of clinical

documentation.

  • Additional responsibility may be assigned by location:
  1. Auditing and review of physician coding. Provide feedback and reporting results to the clinic leaders and

physician based on audit findings

Qualifications

MINIMUM QUALIFICATIONS

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

Minimum Experience:

  • 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

references

  • 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

records.

  • 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

supervisory intervention

  • 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.