Location:
Medical Center - Fort Worth

Department:
HIM-Coding

Shift:
First Shift (United States of America)

Standard Weekly Hours:
20

Summary:

• Requires advanced knowledge of and skill in applying International Classification of Diseases and Procedures (ICD), and Current Procedural Terminology (CPT) code sets and associated Medicare/Medicaid rules and guidelines.
• Reviews and interprets patient medical record documentation to identify pertinent diagnoses and procedures and assigns ICD-10-CM and CPT 4 codes accurately and timely to the highest level of specificity based upon physician documentation for ambulatory surgery, special procedure, observation, emergency department, outpatient ancillary and clinic visit records.
• Primarily codes complex ambulatory surgery and observation visit medical records. Identifies and abstracts specified information from the patient medical record and enters data into the electronic health record system for billing and use in all types of CCHCS reporting.
• Assists with coding outpatient ancillary clinic, specialty clinic and emergency room record coding as necessary.
• Minimum expected accuracy rate for all coding assignments is 95%. Communicates with physicians and other providers regarding documentation requirements and collaborates with Clinical Documentation Specialists on patient cases regarding documentation needs and requirements, and coding assignment accuracy.
• Maintains current knowledge of coding and documentation changes, rules and guidelines.

• RHIA, RHIT or CCS with one (1) year minimum current and continuous full-time ICD-10-CM& CPT-4 ambulatory surgery, observation and/or inpatient coding and abstracting experience required.
• Pediatric coding experience highly desired.
• Technically competent and fluent knowledge in navigation of electronic health record applications, automated encoders, and other software applications and hardware required for job role required.
• Experience using Microsoft Office Excel and Word highly desired.
• Ability to work well independently and productively with minimal guidance and without direct supervision.
• Must be highly detail oriented, have the ability to remain focused with good organization, interpersonal and communication skills.
• Ability to maintain confidentiality. Goal oriented, flexible and energetic. Demonstrates coding skills, and critical thinking skills.
• Ability to solve problems appropriately using job knowledge and current policies and procedures.
• Demonstrated coding knowledge and proficiency is required through on-site skills assessment with a passing score of 90% prior to hire.

• Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) required.
• Required to provide current American Health Information Management Association (AHIMA) continuing education certification records.