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About the role
Key responsibilities & impact- Review clinical documentation to assign and sequence diagnostic and procedural codes for specific patient types to meet the requirements of hospital data or physician data retrieval for billing and reimbursement.
- Validate APC calculations to accurately capture the diagnoses/procedures documented in the clinical record for hospitals.
- Perform documentation review and assessment for accurate abstracting of clinical data to meet regulatory and compliance requirements.
- Interact with client staff and providers.
- Select and sequence ICD-10, and/or CPT/HCPCS codes for designated patient types which may include but not limited to: Ancillary (Diagnostic)/ Recurring; Hospital, Clinic; Physician Pro Fee; Technical Fee or Evaluation and Management.
- Review and analyze facility records to ensure that APC assignments and/or Evaluation and Management codes accurately reflect the diagnoses/procedures documented in the clinical record.
- Abstract clinical data from the record after documentation review to ensure that it is adequate and appropriate to support diagnoses, procedures and discharge disposition is selected.
- Complete assigned work functions utilizing appropriate resources.
- Act as a resource with client staff for data integrity, clarification and assistance in understanding and determining appropriate and compliant coding practices including provider queries.
Requirements
What you’ll need- Required: An active AHIMA (American Health Information Association) credential including but not limited to RHIA, RHIT, CCS, CCA, or an active AAPC (American Academy of Professional Coders) credentials COC (formerly CPC-H), CCS-P, or CPC or related specialty credential.
- Two years of recent and relevant hands-on coding experience.
- Knowledge of medical terminology, anatomy and physiology, pharmacology, pathophysiology, as well as ICD-10 and CPT/HCPCS code sets.
- Ability to consistently code at 95% threshold for quality while maintaining client-specific and/or Savista production and/or quality standards.
- Proficient computer knowledge including MS Office including the ability to enter data, sort and filter excel files, (Outlook, Word, Excel).
- Must display excellent interpersonal and problem-solving skills with all levels of internal and external customers.
- Recent and relevant experience in an active production coding environment strongly preferred.
- Associates degree in HIM or healthcare-related field, or combination of equivalent education and experience.
- Experience using Rcx, Cerner, NextGen (a plus).
Benefits
Comp & perks- Maintain strict patient and provider confidentiality in compliance with all HIPPA Guidelines.
- Participate in client and Savista staff meetings, trainings, and conference calls as requested and/or required.
- Participate in continuing education activities to enhance knowledge, skills, and maintain current credentials.
ATS Keywords
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Hard Skills & Tools
ICD-10 codingCPT codingHCPCS codingAPC calculationsclinical data abstractingmedical terminologyanatomy and physiologypharmacologypathophysiologycoding quality standards
Soft Skills
interpersonal skillsproblem-solving skillscommunication skills
Certifications
AHIMA RHIAAHIMA RHITAHIMA CCSAHIMA CCAAAPC COCAAPC CCS-PAAPC CPC