To be part of our organization, every employee should understand and share in the YNHHS Vision, support our Mission, and live our Values. These values-integrity, patient-centered, respect, accountability, and compassion - must guide what we do, as individuals and professionals, every day.
The Inpatient Coder/Analyst 3 performs activities involving expert inpatient coding of medical records as a mechanism for indexing clinical information used for research, utilization, appropriateness of care, compilation of statistics for hospital regional and government, and accurate reimbursement.
Responsibilities: 1. Coding Expectations - Inpatient coders are expected to perform basic coding functions within departmental established guidelines. 1.1 Accurately assigns ICD-10 codes in accordance with the official coding guidelines. 1.2 Maintains average coding productivity within established departmental guidelines. 1.3 Maintains a 95% coding accuracy score in the application of both ICD-CM and ICD-PCS codes 1.4 Sequences ICD-10 codes appropriately. 1.5 Utilizes features of coding software to ensure complete and accurate representations of the admission and severity of illness through code selection. 1.6 Capable of coding all lengths of stay and all procedure types. 2. Content Knowledge - Inpatient coders are required to maintain industry specific certifications and remain up to date on changes within in the industry. 2.1 Maintains Certified Coding Specialist (CCS) designation per the guidelines set forth by the American Health Information Management Association. 2.2 Participates and seeks out career development activities by reading journals, coding articles and attending in-services and seminars and shares information with the department. 2.3 Regularly utilizes departmental resources to enhance knowledge base. 3. Financial - Inpatient coders are expected to understand the financial impact of their primary duties and work to resolve issues in a timely manner. 3.1 Assists in meeting the corporate Candidate for Billing (CFB) goals by ensuring waiting cases are completed in the timeliest manner via daily review. 3.2 As requested by leadership or Inpatient Coding Specialist, analyzes and resolves issues with cases returned to coding for reviews from other partner departments (i.e. Billing, Denials, CDI, etc.). 4. Clinical Documentation Improvement (CDI) - Inpatient coders are expected to identify documentation and coding query opportunities and refer them to CDI for resolution. 4.1 Develops and maintains advanced knowledge of clinical indicators for all diagnoses. 4.2 Using clinical knowledge, identifies query opportunities for Clinical Documentation Improvement Specialists (CDIS). 5. Problem Solving and Flexibility - Inpatient coders are expected to demonstrate flexibility and critical thinking throughout their workflow. 5.1 Demonstrates critical thinking skills when presented with an issue and develops real time solutions to issues to see cases through to final completion. 5.2 Independently utilizes available resources to resolve coding issues. 5.3 Utilizes CDI for clinical review questions and documentation queries. 5.4 Demonstrates flexibility by accepting and completing other duties as assigned. 5.5 Manages multiple priorities with deadlines. 5.6 May be required to work weekends and holidays as scheduled by leadership. 6. Reporting - Inpatient coders will need to provide leadership data and reports occasionally. 6.1 Provides statistical information to supervisor/manager per departmental guidelines. Maintains activity logs as needed by management. 7. Standards of Performance & Communication - All YNHH employees are expected to demonstrate professional behavior and respect in all their interactions. 7.1 Adheres to Yale New Haven Health Standards of Professional Behavior: Patient-Centered Care, Respect, Compassion, Integrity, and Accountability. 7.2 Communicates in a professional and respectful manner to all individuals across the organization. 7.3 Exhibits enthusiasm for the profession and desire to move the department to more successful position.
High school diploma and two (2) years of college or equivalent with additional training in medical terminology, anatomy and physiology required. Certified Coding Specialist (CCS) certification required at time of hire.
Minimum five (5) years'' experience Inpatient Medical Coding at a large academic medical center required.
CCS certification required.
Knowledge of medical terminology, anatomy and physiology, and disease process. Understanding of ICD-10. Good oral and written communication skills. Ability to exercise good judgment, independent logic, light typing, and excellent computer data entry skills. Computer system experience including familiarity with encoder systems.
Responsible for accurate selection of diagnosis and procedure codes and appropriate determination of correct principle diagnosis and procedure; timely coding and subsequent data entry into hospital billing system; maintenance of 95% coding accuracy rate.
Exercises independent judgment in determining appropriate diagnostic and procedure data from all types of medical record documentation and physician communication. Adapt to changing coding environment and new regulations.