Clinical Coder III - Acute Care - Medical Records

Atrium Health
United States, North Carolina, Charlotte
April 26, 2024
Overview Job Summary Reviews clinical documentation and diagnostic results as appropriate to abstract data and apply appropriate ICD-9-CM/ICD-10-CM/PCS1 and CPT 4 codes for reimbursement, external reporting, research, regulatory compliance, medical necessity, CCI, NCCI and other regulatory edits. Code and abstract medical records of moderate to high complexity within the Primary Enterprise acute care facilities. Essential Functions Reviews moderate to high complexity medical records to identify the appropriate principal diagnosis and procedure codes and all other appropriate secondary diagnoses and procedure codes and assign Present on Admission indicators, Hospital Acquired Conditions and Core Measures for all diagnosis codes. Facilitates appropriate MSDRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines. Reviews charges and Evaluation and Management levels. Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an on-site or remote setting. Abstracts coded data and other pertinent fields in the hospital electronic health record. Ensures the accuracy of data input. Meets established quality and productivity standards. Stay abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding. Physical Requirements Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment. Education, Experience and Certifications. High School Diploma or GED required; Bachelor's Degree preferred. Advanced knowledge in Medical Terminology, Anatomy and Physiology and Pharmacology required. 2 years coding experience in acute care setting required. Current RHIT, RHIA, CPC-H, CIC or CCS required plus a passing score on the Coding test.