Responsibilities:
- Clarifies complex discrepancies in documentation and coding and assures accurate ICD-10-CM and PCS coding/abstracting assignment for inpatient to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care.
- Follows up on complex coding of medical records as a result of internal or external reviews which have identified Coding or DRG discrepancies.
- Supports special studies in relation to coding and abstracting information according to policies and procedures.
- Maintains knowledge and skills via written coding resources, clinical information, videos, etc.
- Meets or exceeds productivity and quality standards and established department benchmarks.
- Extracts pertinent information from clinical notes, operative notes, radiology reports, laboratory reports, (including Pathology), procedure records, specialty forms, etc.
- Determines complex code assignment pertinent to diagnostic workups, surgical techniques, advanced technology and special services.
- Identifies medical and surgical complications and untoward events for accurate MS-DRG / APR-DRG for inpatient charts or APC assignment for outpatient charts.
- Other duties as assigned.
Education:
- High School Diploma is required.
Certifications:
- Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) is required and must be maintained. The Certified Outpatient Coder (COC) by American Academy of Professional Coders will be considered for the outpatient Coder III role.
Complexity of Work:
- Coding assessment relevant to the work may be required.
- Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.
Work Experience:
- A minimum of two years of experience abstracting, identifying, reviewing, and assigning complex ICD-10-CM, PCS codes, POA and PSI indicators, surgical complications for inpatient charts orCPT for outpatient charts is required.
- Successful completion of the Cleveland Clinic Coder Trainee Program with a focus on moderately complex cases may offset the experience requirement.
Physical Requirements:
- Ability to perform work in a stationary position for extended periods.
- Ability to travel throughout the hospital system.
- Ability to work with physical records, such as retrieving and filing them.
- Ability to operate a computer and other office equipment.
- Ability to communicate and exchange accurate information.
- In some locations, ability to move up to 25 lbs.
Personal Protective Equipment:
- Follows Standard Precautions using personal protective equipment.
Pay Range: $22.85 - $34.85 / hour
The pay range displayed on this job posting reflects the anticipated range for new hires. While the pay range is displayed as an hourly rate, Cleveland Clinic recruiters will clarify whether the compensation is hourly or salary. A successful candidate's actual compensation will be determined after taking factors into consideration such as the candidate's work history, experience, skill set, and education. This is not inclusive of the value of Cleveland Clinic's benefits package, which includes among other benefits, healthcare/dental/vision and retirement.