Codes and abstracts documents such as patient charts and pathology reports utilizing diagnostic codes. Enters data into computer system(s).
Essential Duties:
- Codes, abstracts and SMARTS, inpatient, concurrent and/or Ambulatory Surgery and/or Outpatient Records accurately and in a timely period of time in accordance with regulatory agencies, corporate and Hospital specific guidelines/criteria. Assist in ensuring that all medical records contain information necessary for optimal and accurate coding and abstracting. Assist in the retrieval of statistical data from inpatient and outpatient records, as requested by the medical staff and other hospital departments for use in their evaluation and planning and health care related programs, and for research programs.
- POLICIES AND PROCEDURES Implements policies and procedures as directed by Lead Coder and/or Director Understands all coding, abstracting principles and provides input into coding guidelines for all staff. Ability to evaluate and operate systems to determine whether or not current policies and procedures are functioning and makes recommendations to the lead coder for changes.
- CODING Codes Inpatient and Outpatient records utilizing ICD-9-CM and CPT Classification Systems Ability to utilize encoding system to optimize reimbursement
- Codes all cases in accordance with hospital policy and established coding guidelines
- CODING ACCURACY Ability to achieve a 95% accuracy rate as determined by an annual review of coding and/or department quality review(s).
- ABSTRACTING ACCURACY Abstracts pertinent information and achieves a 95% abstracting accuracy rate.
- TIMELINESS OF CODING/PRODUCTIVITY Works with Lead Coder to ensure 95% of patient bills are dropped within 5 days after patient discharge/date of service Works with Lead Coder to ensures the remaining 5% of patient bills are dropped within 2 weeks of discharge/date of service Maintains minimum productivity standards (See HIM Practice Guidelines) and strives to maintain a steady level of productivity and provides consistent effort. Assist other coders in performance of duties including answering questions and providing guidance. Assists Business Office, Admitting and other departments in answering coding questions and/or providing information so that an interim bill can be generated. Assists with physicians, physician office staff and hospital ancillary department staff with diagnostic or procedural coding questions. Assists the Lead Coder in monitoring unbilled accounts to ensure that the oldest records are coded and/or given priority. Assists in the correction of regulatory reports as requested.
- Demonstrates an understanding of policies and procedures and priorities, seeking clarification as needed.
- Participates in continuously assessing and improving departmental performance.
- Works and communicates in a positive manner with management and supervisory staff, medical staff, co-workers and other healthcare personnel.
- SYSTEMS Understands EPF Functionality Understands PBAR Functionality and it’s Interface with Clin-Trac Understands Clin-Trac Functionality and it’s Interface with PBAR Understands and knowledgeable about SMART
- Performs other duties as requested/assigned by Director, Lead Coder or designee.
Required Qualifications:
- Req High school or equivalent
- Req Specialized/technical training; Combined experience/education as substitute for minimum education Successful completion of college courses in Medical Terminology, Anatomy & Physiology and a certified coding class.
- Req 1 year One to three years experience in ICD-9-CM and CPT-4 coding of inpatient and/outpatient records in an acute care facility and experience in using a computerized abstracting, encoding and database systems is required.
- Req Experience in using a computerized coding & abstracting software and an encoding/code-finder database systems.
- Req Demonstrates excellent verbal and written communication skills.
- Req Organization/time management skills.
- Req Able to function independently and as a member of a team.
- Req Demonstrate excellent customer service behavior.
Preferred Qualifications:
Required Licenses/Certifications:
- Req Fire Life Safety Training (LA City) If no card upon hire, one must be obtained within 30 days of hire and maintained by renewal before expiration date. (Required within LA City only)
- Req Certified Professional Coder – CPC (AAPC) AHIMA Certified Coding Associate (CCA); or AHIMA Certified Coding Specialist – Physician (CCS-P); or AHIMA Certified Coding Specialist (CCS); or AAPC Certified Professional Coder – Hospital (CPC-H). If there is the absence of a national coding certificate and the coder possesses any one of the following national certifications, the coder will be required to pass any of the national coding examinations Re: the aforementioned coding certificates within six (6) months of employment: 1. AHIMA Registered Health Information Technician (RHIT) 2. AHIMA Registered Health Information Administrator (RHIA) Successful completion of the hospital specific coding test – with a passing score of ≥70%.
The hourly rate range for this position is $33.00 – $54.02. When extending an offer of employment, the University of Southern California considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, key skills, internal peer equity, federal, state, and local laws, contractual stipulations, grant funding, as well as external market and organizational considerations.