Job Description

The INPATIENT CODER II reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards.

The Inpatient Coder II possesses thorough knowledge and technical expertise of ICD-10-CM diagnoses and advanced understanding of complex surgical procedures which is required for ICD-10-PCS code assignment.  This level of understanding is commensurate with a higher acuity inpatient setting.  This role requires a strong foundation in coding conventions/instructions, Official Guidelines for Coding and Reporting and _Coding Clinics. _ The Inpatient Coder II has a deep understanding of disease process, anatomy/physiology, pharmacology and medical terminology and understands APR and MS-DRG reimbursement methodology.

RESPONSIBILITIES:

• Performs a review of medical record documentation within CAC (computer assisted coding) or Epic to identify the appropriate principal diagnosis, CC’s/MCC’s, other secondary diagnoses and all appropriate procedures 
• Frequently navigates Epic’s Doc Review, Hospital Chart or Chart Review outside of CAC in order to report ICD-10 codes
• Utilizes 3M’s encoder resources to ensure optimal coding accuracy.
• Optimizes CAC to ensure coding efficiency
• Carefully reads CDS documentation within CAC and contacts the CDS when clarification is necessary.
• Collaborates frequently, independently with few internal escalations with Clinical Documentation Specialists when there is a DRG mismatch or query opportunity to ensure clarity and accuracy of medical record documentation.
• Strong written communication skills that follows SBAR (Situation, Background, Assessment, Recommendation) technique.
• Collaborates with CDS on pre-bill holds since it represents potential reimbursement opportunity.
• Pays close attention to single CC/MCC MS-DRG’s and contacts the CDS for clinical validation if not documented within CAC.
• Understands the type and degree of coding necessary when working mortality cases and understands drivers of SOI/ROM (severity of illness and risk of mortality).
• Codes high dollar and interims (30 day length of stay or more) which represent the highest acuity patients at NM.
• Assists OC’s with review of DRG denials and writing appeals.
• Articulates rationale for coding selections when necessary, i.e. data quality audit.
• Maintains diagnosis, procedure, DRG and overall accuracy within department standard of 95% or better.
• Maintains productivity standard within department standard of 90% or better.

Qualifications

REQUIRED:

• 3 years of inpatient coding experience in an acute healthcare setting

• RHIA, RHIT or CCS credential

• AHIMA membership

PREFERRED:

• Associate’s degree in related field
• RHIA, RHIT with CCS credential
• 3 years of inpatient coding experience in a teaching hospital

Additional Information

Northwestern Medicine is an affirmative action/equal opportunity employer and does not discriminate in hiring or employment on the basis of age, sex, race, color, religion, national origin, gender identity, veteran status, disability, sexual orientation or any other protected status.