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Form of work- GENERAL SUMMARY
- Works under the supervision of the Health Information Reimbursement Manager. The primary job function of the Coder Level II is to assign correct ICD-10 and CPT codes to established diagnoses and procedures on all aspects of inpatient and outpatient records. Coding may be performed concurrently or post-discharge. Level II coder must have mastered 2 outpatient work types. Level II coders are required to assist in training new coders and may assist in quality coding checks. Adds or deletes charges for optimal reimbursement as well as compliance by following coding and governmental guidelines. Coder level II's must have a minimum of 1 year acute coding experience to be eligible for level II status as well as meet the above requirements. Performs other duties as assigned.
- QUALIFICATIONS
Education:
- High School Diploma or successful completion of an equivalent High School Exam Required
- Medical terminology required
- Successful completion of an anatomy and physiology course preferred
- Successful completion of coding training program with certification required
Licensure:
- CCA, CPC or any other equivalent coding certification required
Experience:
- Minimum of one year of previous acute coding experience required
- Inpatient coding experience required
Interpersonal Skills:
- Must be able to gather and exchange information with physicians, nurses, and other hospital personnel as well as outside agencies.
Essential Technical/Motor Skills:
- Above average computer skills with the ability to type in order to input information into a computer.
Essential Physical Requirements:
- Ability to lift, push, carry, and file charts. Ability to sit and key for long periods of time.
Essential Mental Requirements:
- Ability to understand written and verbal directions in order to analyze a patient’s medical record. Ability to concentrate and pay close attention to detail for an exceptional period of work time when reviewing and analyzing records for code selection.
Essential Sensory Requirements:
- Ability to see, interpret and read medical information.
Exposure to Hazards:
- None.
Other:
- N/A
- JOB SPECIFIC DUTIESAND PERFORMANCE EXPECTATIONS
- The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.
- Determines sequence of diagnoses according to uniform hospital discharge data set guidelines for inpatient and outpatient records.
- Works closely with documentation specialists to assure optimal coding and reimbursement.
- Assists in Training Level I Coders so that they become educated in processing and billing all work types of coding.
- Maintains productivity and quality standards as set per work type comparable to national averages and benchmarks.
- Passes the annual HIM coding assessment with 70% or above accuracy
- Performs other duties as assigned.
