Job Summary:

The role of a Certified Inpatient Coder at Care New England is to ensure accurate coding and abstracting of all inpatient services, procedures, diagnoses and conditions, working from the appropriate documentation in the medical record. Inpatient services include, but are not limited to cardiac care, intensive care, oncology, behavioral, rehab and multiple other diagnostic grop classifications. Classification systems include ICD-10-CM & ICD-10 PCS as well as other specialty systems as required by diagnostic category. A proficient understanding and execution of inpatient coding guidelines to ensure accuracy of coding and maintain records in accordance with accepted medical and legal standards. Adherence and compliance to various regulatory guidelines from CMS, AHA and AMA.

Duties and Responsibilities:

Analyze medical records, extracting clinical, pathological, therapeutic and epidemiologic data in accordance with established ICD-10-CM coding principles and guidelines.

Review medical records to identify appropriate diagnoses, procedures and selection of appropriate DRG.

Assigns diagnosis and procedure codes from all documentation including procedure notes, operative notes, consultation notes in the medical record using ICD-10-CM & ICD-10 PCS coding classification systems and independently quality checks own work.

Collaborates and communicates closely with CDI department.

Interacts with physicians via coding queries to clarify conflicting/ambiguous documentation within the medical record in order to accurately code patient diagnostic and procedural information.

Ensures that all data abstracted is consistent with guidelines outlined by JCAHO, and CMS, regional and local policy.

Ensure data is optimally coded for documentation capture, financial reimbursement, care planning, statistics and regulatory reporting.

Reviews medical records to determine accurate required abstracting elements (facility/client specific elements) including appropriate discharge disposition to ensure accurate reimbursement.

Demonstrates a comprehensive, expert-level of knowledge of all procedures concerning the sequencing of diagnoses, procedures such as but not limited to those outlined in ICD-10-CM, CPT, Uniform Hospital Discharge Data Set, Medicare guidelines and other appropriate classification systems.

Demonstrates knowledge of anatomy, physiology pharmacology and pathophysiology to interpret general medical classifications for coding discharge data.

Ensures timely record availability by meeting established coding and abstracting CNE productivity and accuracy standards.

Communicates and resolves coding issues around documentation for appropriate follow-up and education.

Interacts and communicates with department lead and manager to clarify and accurately document patient diagnostic and procedural information.

Maintains and complies with policies and procedures for confidentiality of all patient records.

Performs other related duties as assigned.

Requirements:

Minimum high school diploma or GED required.

Must have at least three (3) years hospital inpatient coding experience.

Certification as a Certified Coding Specialist (CCS) and three (3) years of compensatory hospital inpatient coding experience required.

Completion of classes in medical terminology, anatomy and physiology, ICD-10 and CPT coding conventions, and disease process from an accredited program.

Coding certification must be maintained on an annual basis.

Care New England Health System (CNE) and its member institutions, Butler Hospital, Women & Infants Hospital, Kent Hospital, VNA of Care New England, Integra, The Providence Center, and Care New England Medical Group, and our Wellness Center, are trusted organizations fueling the latest advances in medical research, attracting the nation’s top specialty-trained doctors, and honing renowned services and innovative programs to engage in the important discussions people need to have about their health.

Americans with Disability Act Statement: External and internal applicants, as well as position incumbents who become disabled must be able to perform the essential job-specific functions either unaided or with the assistance of a reasonable accommodation, to be determined by the organization on a case-by-case basis.

EEOC Statement: Care New England is an equal opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran or disability status

Ethics Statement: Employee conducts himself/herself consistent with the ethical standards of the organization including, but not limited to hospital policy, mission, vision, and values.