HIM Coder II (Remote)
Description
Caribou Medical Center: Now Hiring - HIM Coder II (Remote)
The HIM Coder II reviews clinical documentation, provider notes, and diagnostic reports to ensure complete and compliant code assignment that supports proper reimbursement and quality reporting. The HIM Coder II works independently with minimal supervision, makes coding determinations for complex cases, and collaborates with clinical staff and providers to clarify documentation when necessary. This position plays a key role in maintaining data integrity, supporting hospital billing processes, and contributing to overall compliance within the Health Information Management department.Core Responsibilities
1. Coding of Outpatient Clinic and ER Records:
a. Accurately and promptly assign ICD and CPT codes to outpatient and ER records.
b. Ensure timely and accurate abstraction of accounts.
c. Query physicians when clarification is needed regarding diagnoses and procedures.
d. Monitor and address unbilled accounts, ensuring they are resolved swiftly.
e. Stay up-to-date on correct coding practices and guidelines.
f. Maintain current knowledge of CMS regulations for outpatient services.
2. Coding of Outpatient Surgery Records:
a. Timely and accurate assignment of ICD and CPT codes to outpatient surgery records.
b. Abstract accounts promptly and accurately.
c. Collaborate with physicians to resolve any coding uncertainties related to diagnoses and procedures.
d. Review unbilled accounts and take appropriate action.
e. Remain informed on current coding practices and CMS guidelines for outpatient services.
3. Coding of Inpatient and Swing Bed Records with DRG Assignments:
a. Assign ICD codes and DRGs for inpatient and swing bed accounts in a timely and accurate manner.
b. Promptly abstract accounts and ensure accuracy.
c. Seek physician clarification on diagnoses and procedures to ensure proper DRG assignments.
d. Monitor unbilled accounts and resolve any discrepancies.
e. Stay informed about appropriate coding practices and CMS regulations for inpatient services.
4. General Department Assistance:
a. Support various departmental functions as needed, including handling release of information requests.
b. Complete assigned special projects efficiently and accurately.
5. Health Information Reporting:
a. Generate requested reports using the abstracting module for Health Information purposes.
6. Clerical Duties:
a. Organize and file completed medical records in compliance with departmental policies and procedures.
b. Ensure records are filed only after physician completion and accurate coding.
c. File records accurately within the Electronic Health Record (EHR) system.
d. Retrieve records for statistical analysis, quality assurance, and final coding at the end of each month.
e. File both completed and incomplete records in appropriate storage areas after final analysis and review.
f. Scan and upload loose reports into the EHR, ensuring correct assignment to the corresponding patient records.
g. Ensure all necessary signatures are present and properly affixed.
h. Retrieve medical records and information for physicians, special studies, and various medical inquiries.
Other Duties as assigned: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for their job. Duties, responsibilities, and activities may change at any time with or without notice.
Work Environment: This role is fully remote.
Requirements
Required
- Minimum 5 years of experience;
- Experience in ICD and CPT coding. Working knowledge of DRG documentation and assignment;
- Prior experience in a healthcare, particularly in a Health Information Management (HIM) department or medical records environment;
- Thorough knowledge of medical terminology, anatomy and physiology, pharmacology, and coding principals.
Preferred
- RHIT or RHIA credentialing;
- Ability to maintain focus on complex and detailed information. Ability to interact effectively with peers and managers. Ability to communicate clearly and effectively with hospital staff and physicians. Ability to handle multiple tasks and changing job assignments.
Remote Work Requirements
- Must maintain a private, secure, and HIPAA-compliant home workspace;
- Reliable high-speed internet connection;
- Ability to work within MST time zone (8:00 am - 5:00 pm);
- Must follow all organization polices related to security, confidentiality, and remote access.