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Coding Specialist III (Medical Records) - Immanuel Medical Center, Omaha, NE
At Conifer Health Solutions, we offer the strength and stability of Tenet Healthcare, a Fortune 500 company, with the ingenuity and energy of a healthcare independent. We are a healthcare solutions company born from the healthcare industry. We take care of hospital business, so hospitals can focus on caring for patients. Ready to be part of our solutions? Welcome to a company that gives you the resources and incentives to redefine healthcare services, with the benefits and leadership to take your career to the next step!
Facilitates improvement in the overall quality, completeness and accuracy of medical record documentation. Obtains appropriate clinical documentation through extensive interaction with physicians, nursing staff, other patient caregivers, and Health Information Management coding staff to ensure the clinical documentation reflects the level of service rendered to patients and is complete and accurate. Educates all members of the patient care team on documentation guidelines on an ongoing basis.
Reports directly to the Operations Director of Medical Records.
Principal Duties And Responsibilities
Analyzes medical record documentation to determine the principal diagnosis and procedures and the presence of co-morbid or complicating conditions associated with the hospital stay.
Assigns ICD-9-CM and CPT 4 codes to diagnoses and procedures according to established guidelines. Assures accurate, optimal coding assignment for reimbursement.
Enters all required clinical data elements from the medical record into the hospital information system to meet hospital and regulatory agencies information needs.
Communicates with physicians either verbally or in writing when it is apparent that documentation in the record is inconsistent or incomplete for accurate coding.
Performs all duties at the standard levels for both quality and quantity of work.
Participates in quality assessment activities and/or productivity tracking in the coding section to continually improve the quality and timeliness of coded clinical data.
Serves as resource to admissions or business services personnel who require coding or DRG and APC information.
Maintains established departmental policies, (including release of medical information and confidentiality standards), procedures and objectives concerning quality assessment, safety, environmental conditions, and infection control.
Assumes responsibility for personal and professional growth through participation in department meetings, inservice programs, and continuing education programs. Fulfills yearly education requirements as stated by policy.
Maintains professional attitude with patients, visitors, and other hospital personnel while assuring confidentiality of patient and other hospital information.
Participates in all safety, security and infection control programs that are mandatory as well as those required and provided by the department.
Demonstrates work practices consistent with Alegent Health and department-specific safety, security and infection control policies.
Must have ability to work effectively and collaboratively in a diverse and multi-cultural environment.
The above statements reflect the general details considered necessary to describe the essential functions of the job as identified, and shall not be considered as a detailed description of all work requirements that may be inherent in the position.
Two-year college program or pursuing a two-year program, including coding instruction and/or two years health care coding experience.
Completion of college level courses in anatomy and physiology with college level instruction in ICD-9-CM and CPT coding systems and/or extensive on the job experience in hospital coding and DRG and APC applications.
One year in an acute care hospital ICD-9-CM, CPT 4, and DRG assignment experience.
Good oral and written communication skills.
Fluent medical terminology and classification systems.
Skilled in reading and interpreting medical record documentation.
Light typing or keyboarding skills.
Ability to operate a computer terminal and multi-line telephone.
Job requires continuous reading skills, occasional verbal communication skills and written communication skills