Medical Records Coder and Abstractor II

Job Overview :

Reviews and interprets clinical documentation to assign accurate and complete codes, modifiers, MSDRG’s, APR-DRG's, SOI, ROM, POA indicators, discharge dispositions and any other clinical data elements required for appropriate reimbursement. Understands and applies reimbursement processes under federal compliance guidelines. Abstracts demographic and clinical data into hospital health information system(s) such as HDM, Epic, or other currently in use. Performs and responds to data quality checks and payer / claims issues. One may specialize in one or more of the standard functions. Specific assignments will vary from day to day based on the needs of the department.

Job Requirements :

Currently enrolled in an approved program for specific field of study in

Within six months of hire, RHIT / RHIA and / or CCS Continuing education pursued in accord with requirements of the accrediting bodies CPC / CCA may be substituted at the hiring manager’s discretion

Proficiency in ICD and CPT coding

DRG’s

MSDRG’s

POA indicators

Post-acute transfer rules

Disposition status

Disease process and treatment

Anatomy and medical terminology

Clinical documentation requirements

AHIMA

Experience in a related field

Job Responsibilities :

Reviews and interprets clinical documentation to assign accurate and complete codes, modifiers, MSDRG's, POA indicators, discharge dispositions, and other data elements required for appropriate reimbursement, meeting established quality and productivity standards within 3 days of visit / discharge. Meets stated metrics for on-time completion.

Collaborates effectively with associate departments as follows, but not limited to : Performs and responds to data quality checks and payer / claims issues with Billing and Denials teams. Works closely with CDMP toward complete documentation for most descriptive coding and DRG , APR-DRG, SOI, and ROM assignment. Obtains final disposition status from Care Coordination. Supports clinical specialty work teams (. OB and Cardiac Surgery)

Abstracts demographic and clinical data into hospital health data management systems.

Participates in audits, training of new employees, education, project teams, etc. as needed.

Other Job-Related Information :

Working Conditions :

Climbing - Rarely

Concentrating - Consistently

Continuous Learning - Consistently

Hearing : Conversation - Frequently

Hearing : Other Sounds - Frequently

Interpersonal Communication - Consistently

Kneeling - Rarely

Lifting

Lifting 50+ Lbs. - Rarely

Lifting

Pulling - Occasionally

Pushing - Occasionally

Reaching - Occasionally

Reading - Consistently

Sitting - Occasionally

Standing - Frequently

Stooping - Occasionally

Talking - Frequently

Thinking / Reasoning - Consistently

Use of Hands - Frequently

Color Vision - Frequently

Visual Acuity : Far - Frequently

Visual Acuity : Near - Consistently

Walking - Frequently

TriHealth SERVE Standards and ALWAYS Behaviors

At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following :

Serve : ALWAYS…

• Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
• Acknowledge when patients / guests are lost and escort them to their destination or find someone who can assist
• Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel : ALWAYS…

Respect : ALWAYS…

Value : ALWAYS…

Engage : ALWAYS…