Position Summary:

The HIM Coder codes and abstracts clinical and demographic data from Emergency Department/Critical Care/Urgent Care and/or Outpatient Ancillary patient records to support reimbursement and reporting. Assists in maintaining accurate and complete medical records in accordance with hospital policies and procedures. Reviews records for completeness, accuracy, and compliance with regulations.

Essential Job Functions:

The essential functions below are not intended to be an exhaustive list of all duties that may be assigned to this position, nor does it restrict the duties which may be assigned to this position if such duties reasonably relate to the position.

• Reviews, codes, and abstracts, utilizing ICD-10 and CPT coding conventions, electronic health records of hospital(s) and clinic(s) patients, both retrospectively and concurrently, in a manner consistent with administrative, ethical, legal and regulatory requirements and to meet company established DNFB standards. Accurately applies ED facility codes (E&M Levels, Infusion & Injections Codes, Modifiers) to each visit. Monitors incoming records daily and provides timely coding according to policy. Maintains strictest confidentiality of protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA).
• Reviews the medical record to ensure specificity of diagnoses, procedures, and appropriate / optimal reimbursement for hospital and/or professional charges. Follows through and requests missing documents/information. Maintains coding data quality and integrity. Maintain standard of 95% accuracy rate on coding reviews. Maintain average hourly productivity standard (coding and abstracting only).
• Abstracts information and statistical data from coded records. Ensures timely completion of history & physical and operative/procedure reports in accordance with governing / regulatory / accrediting agencies regulations.
• Accurately prepares documents/forms/queries and ad hoc report/projects in a timely manner. Reads and responds to emails in a timely manner.

Required Qualifications:

• 2 years as an Emergency Department/Urgent care and/or Outpatient Ancillary coder in an acute care hospital
• High School Diploma or GED
• CCA and/or CPC and/or COC and/or CCS certification
• RHIT and/or RHIA is a plus
• Experience with ACEP (American College of Emergency Physicians) guidelines is preferred
• Experience with multiple different EMR/EHR especially Cerner
• Preferred living/working at Eastern Time Zone
• Excellent written and verbal communication skills