Job description

Analyzes physician/provider documentation contained in assigned Emergency Department (ED) and/or Outpatient Observation/Ambulatory Surgery health records (electronic, paper or hybrid) to determine the principal diagnosis, secondary diagnoses, principal procedure and secondary procedures. Utilizes encoder software applications, which includes all applicable online tools and references in the assignment of Internal Classification of Diseases, Clinical Modification diagnosis and procedure codes, and Current Procedural Terminology / Healthcare Common Procedure Coding System (HCPCS) procedure codes and all required modifiers.

ESSENTIAL FUNCTIONS

Proficiently navigates the patient health record and other computer systems/sources in determination of diagnoses procedures and modifiers to be coded and/or for APC assignment. Codes Emergency Department and/or Outpatient Observation/Ambulatory Surgery utilizing encoder software and online tools and references, in the assignment of ICD-, CPT, and HCPCS codes and modifiers.

Validates and/or revises charges by comparing charges with health record documentation as necessary.

Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures.

Utilizes retrospective edit tool to address possible coding and/or documentation issues related to submitted diagnosis and procedure information obtained from the health record.

Communicates effectively with clinical staff, physicians and office staff regarding documentation issues or needs.

Communicates with case management concerning Outpatient Observation documentation issues.

Collaborates with Patient Financial Services in resolving billing and utilization issues affecting reimbursement.

Identifies concerns and notifies appropriate leadership for resolution. Provides routine problem resolution as needed.

Tracks issues (i.e., missing documentation or charges) that require follow-up to facilitate coding in a timely fashion.

MINIMUM QUALIFICATIONS

Completion of an AHIMA-approved coding program or an AAPC-approved coding program, or Associate’s degree in Health Information Technology or a related field or an equivalent combination of years of education and experience is required.

Bachelor’s degree in Health Information Management (HIM) or related healthcare field is preferred.

Certified Coding Associate (CCA), Certified Procedural Coder Apprentice (CPCA), Certified Procedural Coder (CPC), Certified Outpatient Coder (COC), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) is required.

Two (2) years of current hospital-based acute care coding emergency department and observation or physician coding experience is required.

Current experience performing remote coding is preferred.

Current experience utilizing encoding/grouping software or CAC is preferred. Ability to utilize both manual and automated versions of the ICD and CPT coding classification systems is preferred.

Ability to work with minimal supervision and exercise independent judgment Ability to research, analyze and assimilate information from various on-site or virtual sources based on technical and experience-based knowledge.

Strong problem solving skills. Must be comfortable functioning in a virtual, collaborative, shared leadership environment.

Job Type: Full-time

Pay: $22.00 - $32.93 per hour

Benefits:

• 401(k)
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Education:

• Associate (Preferred)

Experience:

• CPT coding: 1 year (Required)
• ICD coding: 3 years (Required)

License/Certification:

• RHIT (Preferred)

Work Location: Remote

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