Coder II
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Job Description
Coder II responsible for transforming medical records into coded data for reimbursement. Reviewing documentation and ensuring accurate coding in compliance with regulations.
Responsibilities:
- Reviews the content of the medical record for hospital and professional inpatient or outpatient records to identify principal diagnosis, secondary diagnoses and procedures performed that explain the reason for service being provided or the admission and patient severity and comply with standard provider coding regulations.
- Carefully details review of documents such as laboratory findings, radiology reports, various scan reports, discharge summary, history and physical, consultations, orders, progress notes and other ancillary services treatment records needed to ensure all pertinent diagnoses and procedures are recorded.
- Translates all diagnostic and procedural phrases utilized by healthcare providers into coded form using procedure codes as required.
- Using the Encoder software program, determines the codes for all diagnoses and procedures.
- Determines their sequencing to legally maximize reimbursement.
- Assigns the appropriate DRG.
- Assigns codes based on hospital and professional coding guidelines, Coding Clinic directives, federal regulations, CCI coding initiatives, CPT Assistant or other standard coding guidelines.
- Queries physicians as needed to clarify documentation within the patient’s record to facilitate complete and accurate coding.
- Understands and applies internal policy and procedure guidelines regarding how to phrase physician queries.
- Assists the Coding Quality and Professional Manager with training of new coding staff related to hospital and professional coding guidelines, encoder and other software systems needed for the coding process, along with reviewing coding guidelines on an annual basis and makes recommendations for change to improve coding and data management.
- Communicates to Coding Quality and Professional Manager any new diagnoses, procedures, technologies, etc. documented within patient records to ensure that appropriate diagnosis and procedure codes are selected and incorporated into hospital and professional coding guidelines.
- Updates and corrects historical file data by completing and submitting claim action reports per the PHC4 quarterly report.
- Works in conjunction with other areas within the revenue cycle and external departments and Geisinger to ensure coordinated activities with respect to all revenue cycle needs.
Requirements:
- High School Diploma or Equivalent (GED)- (Required)
- Minimum of 3 years-Relevant experience* (Required)
- One of the following certifications required: Certified Risk Adjustment Coder - American Academy of Professional Coders (AAPC), Certified Professional Coder (CPC)- American Academy of Professional Coders (AAPC), Registered Health Information Technician (RHIT) - American Health Information Management Association
- Skills: Communication, Computer Literacy, Medical Records Management, Medical Records Systems, Teamwork, Working Independently
Benefits:
- Health insurance
- 401(k) matching
- Flexible work hours
- Paid time off
- Remote work options
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