Clinical Coder III-Acute Care

Job Req ID: 235981

Position Number: 00127709

Employment Type: Full Time

Shift: Day

Shift Details: 1st shift M-F

Standard Hours: 40.00

Department Name: Medical Records

Location: Corporate Operations

Location Details: Charlotte, with telecommunitng available after onboarding

Carolinas HealthCare System is Atrium Health. Our mission remains the same: to improve health, elevate hope and advance healing - for all. The name Atrium Health allows us to grow beyond our current walls and geographical borders to impact as many lives as possible and deliver solutions that help communities thrive. For more information, please visit carolinashealthcare.org/AtriumHealth

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 Atrium Health 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 UHDDS and other facility guidelines.
• 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; Bachelors 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 Atrium Health Coding test.

At Atrium Health, formerly Carolinas HealthCare System, our patients, communities and teammates are at the center of everything we do. Our commitment to diversity and inclusion allows us to deliver care that is superior in quality and compassion across our network of more than 900 care locations.

As a leading, innovative health system, we promote an environment where differences are valued and integrated into our workforce. Our culture of inclusion and cultural competence allows us to achieve our goals and deliver the best possible experience to patients and the communities we serve.

Posting Notes: Not Applicable

Atrium Health is an EOE/AA Employer