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Coder III - Inpatient/Surgical Outpatient, CCHS Employees Only Job

Date: Jul 16, 2014

Location: Mayfield Hts, OH

Hospital: Main Campus Non-Exempt

Facility: Hillcrest Hospital

Professional Area: Internal Caregiver Experience , Finance/IT

Department: Him Coding

Job Code: U99927

Pay Grade: 12

Schedule: Full Time

Shift: Days


Job Details:


Summary: Identifies, reviews, and assigns complex ICD-9-CM / ICD-10-CM / PCS codes, POA indicators and PSI indicators, surgical complications. Identifies, reviews, and assigns complex ICD-9-CMICD-10-CM and CPT codes, and abstracts clinical information from inpatient/outpatient types. Utilizing established complex coding principles and protocols, identifies, reviews, and assigns ICD-9-CM/ICD-10-CM and CPT-4 codes, and abstracts complex clinical information. All coding and abstracting is for the purpose of reimbursements, research, and compliance with federal regulations and other agencies utilizing established coding principles and protocols.

Job Responsibilities: Clarifies complex discrepancies in documentation and coding; assures accuracy and timeliness of coding/abstracting assignments to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care. Performs follow-up complex coding of medical records as a result of internal or external reviews which have identified Coding or DRG discrepancies. Supports special studies in relation to coding and abstracting information according to policies and procedures. Maintains knowledge and skills; reads current coding resources clinical information, videos, etc. Meets or exceeds productivity and quality standards and established department benchmarks. Extracts pertinent information from clinical notes, operative notes, radiology reports, laboratory reports, (including Pathology), procedure records, specialty forms, etc. Determines complex code assignment pertinent to diagnostic workups, surgical techniques, advanced technology and special services, identifies medical and surgical complications and untoward events for accurate MS-DRG / APR-DRG or APC assignment. Performs other duties as assigned.

Education: Associate's Degree in Health Information Technology from a Commission on Accreditation for Health Informatics and Information Management (CAHIIM) Health Information Management program or Bachelor's degree (CAHIM) in Health Information Management or related field.

Experience: A minimum of three years of experience in the application of ICD-9-CM/ICD-10-CM and CPT-4 coding, recoding and interpreting clinical data from medical records. Must have in-depth knowledge of human anatomy and physiology, disease processes, medical terminology, organization of the medical record, and the medical record coding systems.

Licensure/Certification/Registration: Individuals with an Associate's Degree in Health Information Management must be a Registered Health Information Technician (RHIT). Individuals with a Bachelor's Degree in Health Information Management must be a Registered Health Information Administrator (RHIA). Certified Coding Specialist (CCS) is preferred.

Physical Requirements: Physical demands require standing, walking, sitting, lifting, carrying up to 25 lbs. Close, distant, and color vision is required. Requires manual dexterity to grasp and handle records and to operate a PC computer in the course of work. The work environment is at a moderate noise level (business office with phones, copiers, computers, and printers).


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Healthcare , Surgery , Patient Care , Research , Medical , Medical Coding , Laboratory , Science , Pathology , Radiology , Physiology , Non-Clinical , Finance/Information Systems-j2w , internaljobs