Employment Type:

Full time

Shift:

Day Shift

Description:

Provides high level technical competency and subject matter expertise analyzing physician/provider documentation in Inpatient health records to determine the principal diagnosis, secondary diagnoses, principal procedure and secondary procedures. Assigns appropriate Medicare Severity Diagnosis Related Groups (MS-DRG), All Patient Refined DRGs (APR), Present on Admission (POA), as well as Severity of Illness (SOI) & Risk of Mortality (ROM) indicators for Inpatient records. Identifies Hospital Acquired Conditions (HAC), Patient Safety Indicators (PSI) to ensure accurate hospital reimbursement.

Utilizes encoder software applications, which includes all applicable online tools and references in the assignment of International Classification of Diseases, Clinical Modification (ICD-CM) diagnosis and procedure codes, MS-DRG, APR DRG, POA, SOI & ROM assignments.

Assigns appropriate code(s) by utilizing coding guidelines established by:

• The Centers for Disease Control (CDC), ICD-CM Official Coding Guidelines for Coding and Reporting, Centers for Medicare/Medicaid Services (CMS) ICD-PCS Official Guidelines for Coding and Reporting

• American Hospital Association (AHA) Coding Clinic for International Classification of Diseases, Clinical Modification

• American Health Information Management Association (AHIMA) Standards of Ethical

Coding

• Revenue Excellence/HM coding procedures and guidelines

Navigates the patient health record and other computer systems/sources to accurately determine diagnosis and procedures codes, MS-DRGs, APR DRGs, and identify HACs and PSIs or other indicators that could impact quality data and hospital reimbursement.

Codes Inpatient health records utilizing encoder software and consistently uses online tools to support the coding process and references to assign ICD codes, MS-DRG, APR DRGs, POA, SOI & ROM indicators.

Reviews Inpatient health record documentation, as part of the coding process, to assess the presence of clinical evidence/indicators to support diagnosis code and MS-DRG, APR DRG assignments to potentially decrease denials.

Adheres to Inpatient coding quality and productivity standards established by Revenue Excellence/HM.

Demonstrates knowledge of current, compliant coder query practices when consulting with physicians, Clinical Documentation Specialists (CDS) or other healthcare providers when additional information is needed for coding and/or to clarify conflicting or ambiguous documentation.

Three (3) years of current acute care or Inpatient coding experience is required. Extensive, comprehensive working knowledge of medical terminology, Anatomy and Physiology, diagnostic and procedural coding and MS-DRG, APR DRG assignment. Must be proficient on identifying POA, SOI and ROM indicators for Inpatient records as well as HACs and PSIs to ensure accurate hospital reimbursement.

Current experience utilizing encoding/grouping software and Computer Assisted Coding (CAC) is preferred.

RHIT, RHIA, or CCS credential is required

Our Commitment to Diversity and Inclusion

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.

Our Commitment to Diversity and Inclusion

Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.

Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.

EOE including disability/veteran