Medical Records Coder and Abstractor II
Job Description
Job Overview:
Reviews and interprets clinical documentation to assign accurate and complete codes, modifiers, MSDRG's, APR-DRG's, SOI, ROM, POA indicators, discharge dispositions and any other clinical data elements required for appropriate reimbursement. Understands and applies reimbursement processes under federal compliance guidelines. Abstracts demographic and clinical data into hospital health information system(s) such as HDM, Epic, or other currently in use. Performs and responds to data quality checks and payer/claims issues. One may specialize in one or more of the standard functions. Specific assignments will vary from day to day based on the needs of the department.
Job Requirements:
Currently enrolled in an approved program for specific field of study in
Within six months of hire, RHIT/RHIA and/or CCS Continuing education pursued in accord with requirements of the accrediting bodies CPC/CCA may be substituted at the hiring manager's discretion
Proficiency in ICD and CPT coding
DRG's
MSDRG's
POA indicators
Post-acute transfer rules
Disposition status
Disease process and treatment
Anatomy and medical terminology
Clinical documentation requirements
AHIMA
Experience in a related field
Job Responsibilities:
Reviews and interprets clinical documentation to assign accurate and complete codes, modifiers, MSDRG's, POA indicators, discharge dispositions, and other data elements required for appropriate reimbursement, meeting established quality and productivity standards within 3 days of visit/discharge. Meets stated metrics for on-time completion.
Collaborates effectively with associate departments as follows, but not limited to: Performs and responds to data quality checks and payer/claims issues with Billing and Denials teams. Works closely with CDMP toward complete documentation for most descriptive coding and DRG , APR-DRG, SOI, and ROM assignment. Obtains final disposition status from Care Coordination. Supports clinical specialty work teams (i.e. OB and Cardiac Surgery)
Abstracts demographic and clinical data into hospital health data management systems.
Participates in audits, training of new employees, education, project teams, etc. as needed.
Other Job-Related Information:
Working Conditions:
Climbing - Rarely
Concentrating - Consistently
Continuous Learning - Consistently
Hearing: Conversation - Frequently
Hearing: Other Sounds - Frequently
Interpersonal Communication - Consistently
Kneeling - Rarely
Lifting <10 Lbs - Rarely
Lifting 50+ Lbs. - Rarely
Lifting <50 Lbs. - Occasionally
Pulling - Occasionally
Pushing - Occasionally
Reaching - Occasionally
Reading - Consistently
Sitting - Occasionally
Standing - Frequently
Stooping - Occasionally
Talking - Frequently
Thinking/Reasoning - Consistently
Use of Hands - Frequently
Color Vision - Frequently
Visual Acuity: Far - Frequently
Visual Acuity: Near - Consistently
Walking - Frequently
TriHealth SERVE Standards and ALWAYS Behaviors
At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:
Serve: ALWAYS...
Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
Refrain from using cell phones for personal reasons in public spaces or patient care areas
Excel: ALWAYS...
Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
Offer patients and guests priority when waiting (lines, elevators)
Work on improving quality, safety, and service
Respect: ALWAYS...
Respect cultural and spiritual differences and honor individual preferences.
Respect everyone's opinion and contribution, regardless of title/role.
Speak positively about my team members and other departments in front of patients and guests.
Value: ALWAYS...
Value the time of others by striving to be on time, prepared and actively participating.
Pick up trash, ensuring the physical environment is clean and safe.
Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.
Engage: ALWAYS...
Acknowledge wins and frequently thank team members and others for contributions.
Show courtesy and compassion with customers, team members and the community
Apply Job!