HIM Inpatient Coding Spec II - REMOTE

HIM Inpatient Coding Specialist Level II

Performs all coding and abstracting for Penn Medicine by reviewing medical records and selecting the principal diagnosis, secondary diagnoses, principal procedure, and secondary procedures accurately. Performs analysis of the DRG assigned to produce the highest level of reimbursement to which the facility is legally entitled according to stringent coding and compliance guidelines. Reviews and acts as the gatekeeper for the provider query process, by being the single point of contact with the provider community. Assist the Revenue Cycle Manager by completing the preliminary DRG report for Finance, and compiling additional reports as needed to demonstrate where HIM is in meeting their weekly DNFB goals.

Accountabilities

• Examines the complete medical record to accurately determine the principal & secondary diagnoses, procedures, co-morbidities and complications demonstrating 96% accuracy as determined by audits.

• Sequence the diagnoses & procedures to obtain the optimal DRG or APR-DRG assignment and demonstrates 96% accuracy as determined by monthly audits.

• Demonstrate 95% accuracy for secondary diagnosis coding

• Simultaneously abstracts and enters all coded information into the Epic system for timely billing. This includes the correct discharge disposition verified through the workflow located in Epic.

• Demonstrates a consistent level of performance; strives to maintain a steady level of productivity according to the following guidelines:

o HUP & PPMC

•Average of 15 inpatient records coded daily

o PAH, CCH, and Princeton

•Average of 19 inpatient records coded daily

•Process retrospective queries at any facility. Productivity standard of 22 per day

• Must possess the ability to code all facilities while maintain the accuracy and productivity standards sets above

• Refers charts that require clarification of vague or unclear documentation for accurate coding and DRG assignment to a Coding Quality Specialist to query the physician for the needed documentation.

• Promptly and accurately assigns Coding Hold reasons to all records that cannot be completed immediately due to:

o Missing Operative Notes

o Missing Pathology Report

o Physician Query Needed

o Mortality Review

o Discharge Disposition

o Missing Other Reports (Card Cath, EPS, etc)

• Is willing to adjust schedule to complete workload and meet pivotal revenue cycle deadlines when requested by management. Cooperates with departmental work volumes by adjusting work schedule.

• Correctly identifies and applies Present on Admission indicators to all applicable diagnoses according to designated guidelines. Accuracy is important due to the far reaching impact on reimbursement and quality metrics.

• Consistently codes the oldest cases first and prioritizes high dollar cases over 4 days old first.

• Strives to become fluent in the inpatient coding at all of the UPHS facilities.

• Performs revenue cycle/DNFB activities as needed

• Reviews and processes provider queries. This includes working with the coding staff to appropriately write the query as well as communicating with the provider community to ensure the query is answered.

• Responsible for continuing education both inside and outside the organization along with tracking Continuing Education credits to maintain professional credentials.

• Performs duties in accordance with Penn Medicine and entity values, policies, and procedures

• Other duties as assigned to support the unit, department, entity, and health system organization

Minimum Requirements

Required Education and Experience

• H.S. Diploma/GED is required.

• 1-year experience in coding inpatient medical records is required.

• Bachelor's Degree Health Information Management or a related field is preferred.

Licenses, Registrations, and Certifications

• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT) is preferred.

• Certified Coding Specialist (CCS) is required.

Required Skills and Abilities

•Demonstrated ability to code at each of the three facilities (HUP, PPMC, PAH) while maintaining the appropriate accuracy and production levels (applies to internal applicants only)

•Extensive knowledge of medical terminology, human anatomy and physiology, and clinical disease processes

•Extensive knowledge of ICD-10-CM and ICD-10-PCS

•Ability to assess, prioritize and complete multiple tasks in a stressful environment

•Familiarity with computerized encoders

As part of our COVID-19 response, this position may currently be offering partial or full remote work. However, in the near future this position will require full or partial on-site work.

Be a part of the exciting and ground-breaking upcoming years for the Penn Medicine Information Services department!

Because growth is essential to continuing to meet the current and future needs of patients, Penn Medicine continues to expand its capabilities.

Penn Medicine's Information Services (IS) Department focuses its efforts on the clinical and financial systems that support the day-to-day operations of six (6) hospitals, several satellite practices, and more than 8,923 physicians.

Learn more about Information Services