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Outpatient Coder Coordinator in Harlingen, TX at Prime Healthcare Services Inc

Date Posted: 5/7/2019

Job Snapshot

Job Description


The Outpatient Coder Auditor reviews and analyzes documentation present in the medical record for outpatient visits to ensure accuracy of diagnosis and procedure codes assigned by the Coders or Clinical Documentation Specialists (CDS) or Computer Assisted Coding (CAC) software. The Outpatient Coder Auditor finalizes the coding and abstracting of the medical record upon ensuring the assignment of International Classifications of Diseases, Ninth Revision (ICD-9-CM) or Tenth revision (ICD-10/PCS), Current Procedural Terminology (CPT), and Health Care Procedure Coding System (HCPCS), are accurate and supported by the clinical documentation of the respective medial record. Holding a senior coding position, assumes primary responsibility for DRG validation/accuracy, primary role in assisting CDS and medical staff members with improving quality of clinical documentation. Participates in chart review projects as assigned and other duties as needed.

Maintain confidentiality, protecting patient information at all times: minimum information necessary to those with right and need to know.

Conduct a thorough review of the documentation available in the record, and accurately assign the appropriate principal and secondary, diagnoses and procedures.

Audit assignment of CPT codes per coding conventions & general guidelines published by the American Medical Association (AMA) for surgical and diagnostic procedure coding and in accordance to American Hospital Association (AHA) Coding Clinic for HCPCS.

Follow coding guidelines as specified by AHA Coding Clinics and the Hospital policy. Commit to code assignment and data reporting in an unbiased, honest and ethical manner.

Audit if patient data correctly and accurately abstracted in a complete manner with all required elements in the electronic information system. Follow department policy and UHDDS abstracting guidelines, facilitating a positive outcome including OSHPD error reports (for California only).

Ensure all pertinent documentation is available in the record for final coding and abstracting.

Discrepancies identified upon review of the medical record, for example in the content and quality of the transcribed report, are addressed appropriately.

Consult with medical staff members when necessary, for purposes of clarification of diagnoses and/or procedures.

Provider queries are formulated well in compliance with industry guidelines and hospital policies and are clear and concise. Will track and monitor the provider queries for reconciliation, delinquency and assist the medical staff members to secure a timely response for complete clinical documentation and accurate final coding.

Seeks all relevant and necessary documentation prior to finalization of coding. Tracks accounts that a pended for additional documentation. Reconciles coding when and if additional clinical documentation is added or amended after final coding.

Acts as a liaison assisting medical staff members through education and feedback to improve the quality of documentation within the body of the medical record.

Follow the Department policy for prioritization of records to be coded, including STAT requests.

Consistently update coding status in the abstract module. Monitor un-coded records, taking initiative to resolve any issues and ensure timely abstracting and coding of data.

Serve as a role model and provide mentorship, assisting in the professional development of the Coders and CDS staff members.

Perform chart review as assigned.

For old paper based charts, consistently file medical records in strict terminal-digit order and utilize the chart location system. For new electronic based charts, ensure maintenance of the records according to the established processes to maintain the integrity of the electronic health record.

Complete job duties in accordance with productivity requirements and quality standards.

Maintains current AHIMA certification. Submits copy to the Department Director/Manager or Human Resources in a timely manner.

Initiate & participate in required and voluntary continuing education opportunities, enhancing professional growth and maintaining CEU’s required for certification and/or by department policy.

Promptly report equipment malfunctions to the appropriate personnel to order service as needed.

Inventory supplies needed to perform job duties and place order on a regular basis to ensure an adequate supply at all times.

Performs other duties as assigned or required.

  1. Medical Graduate, PA or Nursing Graduate required.
  2. 1+ year of clinical experience in acute care setting preferred.
  3. Please note that in order to be promoted to Coder Auditor I position; the Employee must meet certain performance standards as defined by the Hospital/ Department.
  4. Minimum of two years’ experience with ICD-9 and CPT coding in an acute care setting preferred.
  5. Basic computer experience required.
  6. Use of an encoder software product for code assignment in an acute care setting required
  7. Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred
  8. Excellent written and verbal communication skills. Excellent critical thinking skills.
  9. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
  10. Ability to work independently in a time-oriented environment.
  11. Computer literacy and familiarity with the operation of basic office equipment.

We are an Equal Opportunity/Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics.  If you need special accommodation for the application process, please contact Human Resources.  EEO is the Law: