**This position is remote, however candidates must be local to MD to be able to attend regular meetings onsite**
The Coding Specialist II abstracts data from electronic medical records into computerized databases to provide accurate and timely information for reimbursement. This individual will also assign codes to ICD-10-CM, ICD-10-PCS and CPT procedures according to ICD-10, CPT, Coding Clinic, Internal and Official Coding Guidelines. Gives guidance to Coding Specialist I.
CAREER DEVELOPMENT: Maintains and improves professional and technical expertise. Participates in coder related, hospital-sponsored in-service training sessions to ensure skills are fresh and up-to-date. Proactive in addressing compliance issues; reporting through appropriate channels such as supervisor, chain of command and Ethics Point. Coding quality reflects utilization of available resources (e.g. reading publications pertaining to coding). Completes mandatory introductory and ongoing training within the specified timeframes.
DATA ABSTRACTION: Abstracts data from medical records into computerized database to provide accurate and timely information for case mix and reimbursement. Accurately, abstract required fields: attending, admit & discharge dispositions, admit and discharge facilities as appropriate, date of procedure and surgeon as appropriate. Updates the data base as changes are received.
OUTPUT CODING: Assigns codes to diagnoses, procedures and POA as appropriate in according to ICD-10-CM, ICD-10-PCS, CPT, Official Coding Guidelines, Coding Clinic and Internal Coding Guidelines. Sequence codes accurately for appropriate APR-DRG and SOI assignment. Write a non-leading query to provider via electronic to clarify diagnoses and procedures. Provides education to Physicians on appropriate documentation needs for coding.
QUALITY AND QUANTITY OF WORK: Ensures quality and quantity of work in order to meet productivity standards.
Normal Newborn: 4 to 5 charts per hour
OB Delivery (> 4 LOS): 3 to 5 charts per hour
Medicine/Hospitalist (> 4 days LOS): 3 to 5 chart per hour
All other inpatient: 2 to 5 charts per hour
Observation: 3 to 5 charts per hour
Ambulatory/Extended Recovery: 4 to 6 charts per hour
Other Outpatient Visits: 5 to 8 charts per hour
Serpick CPT Review: 8 to 10 charts per hour
Multi-D Visits: 8 to 10 charts per hour
Emergency: 8 to 10 charts per hour
Outpatient Labor & Delivery: 8 to 10 charts per hour
What You Need to Be Successful:
High School Diploma or GED is required.
2 year / Associate's Degree: Business (preferred).
Vocational / Technical Degree (preferred)
**Combination of relevant education and experience may be considered in lieu of degree.
Certification / Licensure / Registration
CCS is preferred.
CPC-H is preferred.
RHIT is preferred.
Experience and Skills
2-4 years of Medical Coding experience is required; InPatient coding experience preferred.
2-4 years' working knowledge of medical terminology, human anatomy and coding skills including ICD-10-CM, ICD-10-PCS & CPT coding are required.
1-2 years (computer skills) in 3M Encoder, HDM Abstract and EPIC electronic medical records (EMR) is preferred.
4-6 years Previous inpatient coding experience, medical terminology, and human anatomy and pharmacology preferred.
4-6 years' strong understanding of ICD-10-CM, ICD-10-PCS, Advanced CPT coding, and APR-DRG Grouper experience, MHAC (Maryland Hospital Acquired Conditions) and POA (Present on Admission) is preferred.
Required skills: working knowledge of computers, excellent organizational skills, demonstrated high degree of coding accuracy, excellent data entry, independent, focused individual able to work remotely as needed.