HEALTH INFORMATION MANAGEMENT CODER - HEALTH INFORMATION MANAGEMENT

AFSCME 1178

Under the supervision of a Coding Supervisor, the Health Information Management (HIM) Coder abstracts relevant clinical and demographic information from the medical record to identify the care rendered to the patient for the purpose of reimbursement, research and compliance.

The HIM Coder ensures that the medical record reflects accurate attending physician documentation for coding of physician and facility encounters. Assigns ICD-10-CM and PCS codes, CPT-4, and HCPCS Level II codes in accordance with coding and reimbursement guidelines for physician and facility encounters.

Abstracts into a group and assigns Diagnosis Related Group (DRG) on inpatient accounts and applies Ambulatory Payment Classifications (APC) to outpatient accounts. With minimal errors, identifies principal and secondary diagnosis and procedures based upon federally mandated requirements, corporate requirements, and hospital policy. Maintains productivity standards and quality accuracy of 95% or above.

TYPICAL DUTIES

• Identifies and codes the principal and secondary diagnosis and procedures using ICD-10-CM and PCS, E/M, CPT-4, and HCPCS Level II codes with minimal errors as needed.
• Sequences diagnoses and procedures in accordance.
• Abstracts specific data and enters into the clinical abstracting database.
• Utilizes the encoder and other related databases and references to minimize coding errors.
• Attends departmental required in-service and training in-service programs.
• Attends the Hospital's annual in-service and training programs.
• Adheres to section/departmental procedures for work assignments.
• Meets quality and productivity standards.
• Adheres to the Departmental Standard Practices Guidelines.
• Adheres to Hospital attendance policies.
• Adheres to environmental requirements.
• Meets the standard for compliance of Continuing Education (CE) as defined by the American Health Information Management Association (AHIMA) or other licensing/certification agency.
• Performs assignments as scheduled with or without supervision.
• Maintains the confidentiality of information.
• Maintains a cooperative working relationship with the Health Information Management team.
• Works flexible hours including weekends, holidays and various shifts.
• Performs other duties as assigned, as required.

MINIMUM QUALIFICATIONS

• A High School Diploma or G.E.D., is required (Must provide high school diploma at time of interview)
• One (1) year of coding experience within the last two (2) years, is required.
• Applicants must possess one or more of the following certifications, is required:

o Registered Health Information Administrator (RHIA) (AHIMA).

o Registered Health Information Technician (RHIT) (AHIMA).

o Certified Coding Specialist (CCS) (AHIMA).

o Certified Coding Specialist-Physician Based (CCS-P) (AHIMA).

o Certified Professional Coder (CPC) (AAPC).

• Must be able to work flexible hours, including weekends, holidays and various shifts, is required

PREFERRED QUALIFICATIONS

• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) is preferred.

KNOWLEDGE SKILLS, ABILITIES, AND OTHER CHARACTERISTICS

• Knowledge of Microsoft Office Excel and Word.
• Working knowledge of ICD9-CM and PCS, ICD10-CM and PCS.
• Working knowledge of CPT-4.
• Working knowledge of HCPCS Level II Codes.
• Excellent verbal and written communication skills necessary to communicate with all levels of staff and a patient population composed of diverse cultures and age groups.
• Ability to code utilizing a computerized encoder/abstracting system.
• Ability to operate a PC in a windows environment.
• Ability to multi-task and meet deadlines in a fast paced and stressful environment.
• Ability to adhere to department policies and standards utilizing best practices.
• Ability to maintain a professional demeanor and composure when challenged.
• Ability to work flexible hours, including weekends.
• Ability to maintain a high level of discretion and maintain confidentiality.
• Demonstrate attention to detail, accuracy and precision.

PHYSICAL AND ENVIRONMENTAL DEMANDS

This position is functioning within a healthcare environment. The incumbent is responsible for adherence to all hospital and department specific safety requirements.

This includes but is not limited to the following policies and procedures: complying with Personal Protective Equipment requirements, hand washing and sanitizing practices, complying with department specific engineering and work practice controls and any other work area safety precautions as specified by hospital wide policy and departmental procedures.

The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of the personnel so classified.

For purposes of the American with Disabilities Act, “Typical Duties” are essential job functions.

BENEFITS PACKAGE

• Medical, Dental, and Vision Coverage
• Basic Term Life Insurance
• Pension Plan
• Deferred Compensation Program
• Paid Holidays, Vacation, and Sick Time
• You may also qualify for the Public Service Loan Forgiveness Program (PSLF)

For further information on our excellent benefits package, please click on the following link: http://www.cookcountyrisk.com/

VETERAN PREFERENCE

PLEASE READ

When applying for employment with the Cook County Health & Hospitals System, preference is given to honorably discharged Veterans who have served in the Armed Forces of the United States for not less than 6 months of continuous service.

To take advantage of this preference a Veteran must

Meet the minimum qualifications for the position.

Identify self as a Veteran on the employment application by answering yes to the question by answering yes to the question, “Are you a Military Veteran?”

Attach a copy of their DD 214, DD 215 or NGB 22 (Notice of Separation at time of application filing. Please note: If you have multiple DD214s, 215s, or NGB 22S, please submit the one with the latest date.

Coast Guard must submit a certified copy of the military separation from either the Department of Transportation (Before 9/11) or the Department of Homeland Security (After 9/11). Discharge papers must list and Honorable Discharge Status. Discharge papers not listing an Honorable Discharge Status are not acceptable.

OR

A copy of a valid State ID Card or Driver’s License which identifies the holder of the ID as a Veteran, may also be attached to the application at time of filing.

If items are not attached, you will not be eligible for Veteran Preference

VETERANS MUST PROVIDE ORIGINAL APPLICABLE DISCHARGE PAPERS OR APPLICABLE STATE ID CARD OR DRIVER’S LICENSE AT TIME OF INTERVIEW.

MUST MEET ALL REQUIRED QUALIFICATIONS AT TIME OF APPLICATION FILING.

• Degrees awarded outside of the United States with the exception of those awarded in one of the United States’ territories and Canada must be credentialed by an approved U. S. credential evaluation service belonging to the National Association of Credential Evaluation Services (NACES) or the Association of International Credential Evaluators (AICE). Original credentialing documents bust be presented at time of interview.
• Please note all offers of Employment are contingent upon the following conditions: satisfactory professional & employment references, healthcare and criminal background checks, appropriate licensure/certifications and the successful completion of a physical and pre-employment drug screen.
• CCHHS is strictly prohibited from conditioning, basing or knowingly prejudicing or affecting any term or aspect of County employment or hiring upon or because of any political reason or factor.

COOK COUNTY HEALTH & HOSPITALS SYSTEM IS AN EQUAL OPPORTUNITY EMPLOYER