Job Description

HIM Coder Lead
Job CategoryClerical
ScheduleFull time
Shift1 - Day Shift

SUMMARY:

Assists Manager with the review and assignment of work to staff responsible for the timely and accurate coding of administrative and clinical data through the accurate assignment of ICD-10-CM, ICD-10-PCS and/or CPT codes while complying with the regulations and requirements of the Federal Government, State licensing agencies and the hospital’s policies and procedures. Performs audits and provides necessary training for inpatient or outpatient coding staff. Recommends and coordinates performance improvement initiatives under the direction of the Manager.

ESSENTIAL FUNCTIONS:

Assists the Manager with the review, assignment, training, and direction to HIM Coders, to ensure the correct ICD-10-CM, ICD-10-PCS and/or CPT code to each diagnosis and operative procedure are substantiated by documentation contained in the medical record.

Follows departmental and official ICD-10-CM, ICD-10-PCS and/or CPT coding guidelines to ensure consistent and accurate coding of diagnostic and procedural data.

Assists Manager with the instruction staff in the use of the 3M HDM and 360 R2 CAC System for proper coding.

Assists with the determination that the medical staff documents have sufficient information for accurate coding and appropriate reimbursement by utilizing clarification forms when necessary.

Assists physicians, their office staff, patient financial services, quality management and other hospital personnel with coding and DRG/APC questions.

Trains staff how to determine the sequence of diagnoses according to UHDDS (Uniform Hospital Discharge Data Set) guidelines.

Inputs abstract data and codes into computer to gather administrative and clinical data for distribution to outside regulatory agencies, third party payers, administrative staff and physicians.

Assists with and requests diagnoses from physicians when not recorded on discharge or if information is incomplete.

Prepares activity reports for management and conducts audits to ensure accuracy of coding and compliance with standards.

Maintains current knowledge of coding principles and guidelines as coding conventions are updated.

Assists in the development of programs and procedures to ensure a 95% coding accuracy rate.

Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.

Performs related duties as assigned.

MINIMUM QUALIFICATIONS

EDUCATION: Completion of a 2-year college or technical school curriculum in Health Information Management, or an equivalent combination of relevant education and experience. Preferred is the completion of a 4-year college curriculum in Health Information Management.

EXPERIENCE: Three (3) years of related hospital record coding experience in an acute care hospital setting; preferably in a lead role.

LICENSURE OR CERTIFICATION: Requires one or more of the following: Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Coding Specialist-Physician-based (CCS-P), Certified Professional Coder (CPC2), Certified Inpatient Coder (CIC) or Certified Outpatient Coder (COC).

KNOWLEDGE, SKILLS AND ABILITIES: 

  • Knowledge of ICD-10-CM, ICD-10-PCS, CPT, UHDDS sequencing, and MS-DRG, APR-DRG and APC reimbursement models.

  • Knowledge of the 3M HDM and 3M 360 R2 System for proper coding and other HIM computer applications and software.

  • Knowledge of coding principles and guidelines and home coding work flow applications.

  • Knowledge of medical records and the evaluation of medical records for in-patient or out-patient.

  • Skill in the use of HIM computer systems and applications.

  • Skill in both verbal and written communications.

  • Skill in the attention to detail to ensure the utmost accuracy for the data entry of medical record information

           and proper coding.

  • Ability to prepare training materials and train staff in proper coding methods and techniques to ensure compliance with all federal, state and hospital regulations.

  • Ability to identify problems and recommend operational solutions.

  • Ability to read, analyze and interpret professional journals, governmental regulations, and coding

          guidelines.

  • Ability to provide analytical skills and be aware of the importance of position in record flow.

  • Ability to maintain good working relationships and communication with the medical staff, nursing,

          administration and other ancillary departments with the hospital.

  • Ability to accurately perform multiple tasks and observe strict deadlines.

    PHYSICAL DEMANDS AND WORK ENVIRONMENT:  The physical demands and work environment described here are representative of that which an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

    While performing the duties of this job, the employee is regularly required to sit; use hands and fingers to handle or feel; reach with hands and arms; and talk or hear. The employee is occasionally required to stand; walk; and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 25 pounds without assistance. Specific vision abilities required by this job include close vision, and color vision.  While performing the duties of this job, the employee is occasionally exposed to toxic or caustic chemicals; may potentially be exposed to infectious organisms during routine and emergency situations. The noise level in the work environment is usually moderate.

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