Health Information Management Coding Specialist

Under general supervision, this position reviews, analyzes and abstracts data from the medical record to assign correct diagnoses, etiologic, and procedure codes as documented by clinicians Accurately codes inpatient, outpatient and clinic charts to ensure compliance with correct coding guidelines to ensure proper reimbursement. Uses ICD-10-CM, ICD-10-PCS, HCPCS and CPT codes (as appropriate).

• Reviews, analyzes and abstracts data from the medical record to assign correct diagnoses, etiologic diagnoses and procedure codes as documented by clinicians.
• Accurately codes inpatient, outpatient, and clinic charts to ensure compliance with correct coding guidelines using ICD-10-CM, ICD-10-PCS, HCPCS and CPT codes (as appropriate) to ensure correct billing and reimbursement.
• Reviews physician documentation and sends queries to clarify diagnostic information to be able to code to the greatest level of specificity.
• Reviews Impairment Group Codes (IGC) assigned by physicians and works with the Prospective Payment System (PPS) Coordinator to ensure accurate IGC assignment.
• Assigns etiologic diagnosis codes on inpatient charts for use on the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI).
• Works at an established coding productivity rate to be determined by the Manager of HIM and/or the Chief Financial Officer (CFO).
• Works with the PPS Coordinator to ensure coding information is entered into the Uniform Data Services (UDS) system for transmission of the IRF-PAI to the CMS Secure Access Portal.
• This position works remotely part or all of the time according to the discretion of the Manager of HIM.
• Works with Patient Financial Services, Accounting and other RHI service areas to answer coding and documentation questions.
• Acts as a documentation, coding and IGC resource for RHI physicians and develops training and tools as needed.
• Works as a team with the rest of the HIM department to improve clinical documentation practices at RHI.
• Assists other staff in the HIM department with daily tasks such as the processing of Release of Information requests, answering phone calls, and scanning as needed.
• Works as a team with the rest of the HIM staff to pull data for third party audit requests, quality improvement activities and accreditation activities.
• Performs special projects as assigned by RHI Leadership and the Manager of HIM.
• Uses appropriate techniques in performing duties to avoid or minimize accidents and injury related to unsafe practice. Proactively seeks information and resources, including the Environment of Care Manual, to aid in safe performance of duties to contribute to the RHI culture of safety.
• Is focused on providing customer satisfaction (including, but not limited to, patients, co-workers, visitors, vendors and physicians) as a primary goal/outcome of all interactions and places customer first in the performance of job duties.
• Understands and exhibits the principals of service excellence, leads by example, and mentors' others in the performance of their assigned duties. Additionally, understands that every employee is responsible for exhibiting exceptional customer service by answering call lights on the nursing unit and if not able to assist personally, will inform the appropriate employee regarding the patient's need.
• Understands the role of employee's individual position regarding HIPAA requirements and level of access to Protected Health Information as defined in HIPAA hospital-wide polices.
• Understands that it is the responsibility of every RHI staff member to provide patient safety as a priority response according to RHI evidence-based practices. Encourages patients to be actively involved in their own care as patient safety strategy.
• Responds to department needs in a timely manner as evidenced by the absence of legitimate customer complaints.
• Performs other duties as assigned.

PERIPHERAL JOB DUTIES

• Attends committee meetings as needed and assigned.
• Participates in and/or facilitates training activities as needed and assigned.

• Strong knowledge of ICD-10-CM, ICD-10-PCS, CPT, HCPCS and correct coding guidelines.
• Prior experience successfully coding inpatient and outpatient IRF charts.
• Strong knowledge of Impairment Group Codes (IGC) assignment.
• Strong knowledge of the IRF Prospective Payment System (i.e., presumptive compliance, CMG assignment, comorbidity tiers, etc.) and the IRF-PAI required.
• Strong knowledge of how a healthcare Revenue Cycle System functions.
• Strong knowledge of appropriate medical record documentation practices.
• Strong knowledge of Health Information Management practices.
• Proficient in MS Word, Excel, Access, and PowerPoint.
• Experience using an encoder for coding purposes.
• Experience conducting training sessions pertaining to correct documentation and coding practices.
• Excellent communication skills.
• Ability to organize work priorities and meet specific objectives under time constraints.
• Ability to manage multiple tasks simultaneously.
• Good problem-solving skills and attention to detail.
• Ability to be a team player in a team-oriented environment.
• Acts as a leader in change management.

EXPERIENCE

• At least two years prior experience successfully coding IRF inpatient and outpatient charts required.
• Prior experience working in a healthcare Health Information Management and/or Revenue Cycle department required.
• Strong knowledge of commercial and government payer rules preferred.
• Strong knowledge of appropriate medical record clinical documentation processes preferred.

SPECIAL TRAINING, LICENSURE, CREDENTIALING

• A Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) IN ADDITION to another advanced certification in the HIM or medical field required.
• CCS and Licensed Practical Nurse (LPN) other medical credential such as Registered Nurse (RN), Respiratory Therapist (RT), Emergency Medical Technician (EMT), etc.
• CCS and RHIT credential
• CPC and Clinical Documentation Improvement Professional (CDIP) credential

EDUCATION

• Successful completion of a CAHIIM-accredited Associates Degree, Bachelor's Degree or certificate program specializing in Health Information Management and/or billing and coding preferred.
• Successful completion of an accredited medical or allied health education program also accepted.

EQUIPMENT USED

• Standard computer system
• Electronic medical record system
• 3M Encoder
• Online coding resources
• Standard office equipment

HOURS

• Monday-Friday 7:00 AM-4:00 PM

The Rehabilitation Hospital of Indiana is an equal opportunity employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability status, protected veteran status, sexual orientation, or any other characteristic protected by law.