Medical Coder 2

Summary

The coding specialist, utilizing the clinical documentation management program and clinical knowledge, analyzes inpatient and outpatient medical records for completeness of documentation, contacting the appropriate provider for additional documentation if needed. Accurate diagnosis and procedure codes are then assigned based on the documentation in the medical record, which directly impacts the appropriate DRG assignment for reimbursement. Critical data elements are abstracted by the Coding specialist on all inpatient discharges. This information is used by the organization for decision making.

Responsibilities

(60%)* Assigns accurate ICD-CM diagnosis and procedure codes and CPT codes in a timely manner for all appropriate encounters and ensures appropriate DRG assignment based on the clinical documentation within the medical record by using CMS and American Hospital Guidelines and following AHIMA code of ethics.

(30%)* Utilizes clinical knowledge to interact with the Clinical Documentation Specialists and physicians/providers on a daily basis to assist in improving documentation within the medical record; to accurately reflect the severity of illness and level of care provided.

(10%)* Demonstrates willingness to participate in continuing education to enhance coding knowledge.

OTHER DUTIES AND RESPONSIBILITIES:

Meets established productivity guidelines.

Other duties as assigned.

MyMichigan Health is a technology driven organization and employees need to demonstrate competency in Microsoft Windows.

An employee may be required to participate in further learning opportunities offered by MyMichigan Health.

Certifications and Licensures

E/M CODER: CPC, CCS, CCSP, RHIT, OR RHIA

Effective October 1, 2013, new hires must be RHIA or RHIT eligible and successfully complete the certification exam within six (6) months of hire and maintain the certification to meet the requirements of the position. 

FINGERPRIN: Fingerprinting

Required Education

Associate's degree is required

Other Information

EXPERIENCE, TRAINING AND SKILLS:

Coding experience from an AHIMA approved internship required or successfully completed an independent study program offered by AHIMA.

Knowledge of medical terminology and anatomy.

Written, oral, organizational and interpersonal skills needed to communicate successfully.

PHYSICAL/MENTAL REQUIREMENTS AND TYPICAL WORKING CONDITIONS:

Exposure to stressful situations, including those involving public contact, as well as, trauma, grief and death. 

Able to wear personal protective equipment that includes latex materials or appropriate substitute if required for your position.

Is able to move freely about facility with or without an assisted device and must be able to perform the functions of the job as outlined in the job description. 

Overall vision and hearing is necessary with or without assisted device(s).

Frequently required to sit/stand/walk for long periods of time. May require frequent postural changes such as stooping, kneeling or crouching. 

Some exposure to blood borne pathogens and other potentially infectious material.

Ability to handle multiple tasks, get along with others, work independently, regular and predictable attendance and ability to stay awake.

Overall dexterity is required including handling, reaching, grasping, fingering and feeling.  May require repetition of these movements on a regular to frequent basis.

Physical Demand Level: Sedentary.  Must be able to occasionally (0-33% of the workday) lift or carry 0-10 lbs.