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Senior Clinical Coding Specialist - Inpatient
Mission Statement
The mission of The University of Texas M. D. Anderson Cancer Center is to eliminate cancer in Texas, the nation, and the world through outstanding programs that integrate patient care, research and prevention, and through education for undergraduate and graduate students, trainees, professionals, employees and the public.
Summary
The primary purpose of the Senior Inpatient Clinical Coding Specialist position is to…
Analyzes medical records and abstracts clinical data by assigning codes from patient records in accordance to coding classification systems. Reviews patient encounters for accurate code assignment of all relevant diagnosis, present on admission, patient safety indicators and procedures. Enters appropriate codes into the 3M encoder hospital's mainframe computer for the transfer of data to billing files for reimbursement. Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous or unclear for coding purposes. Serves as a resource for other departments users related to the abstracted coded data.
- Effectively communicate and interact with members of the inpatient coding team, management, peers, business office, and external customers
- Provides excellent and supportive feedback to management and coordinators for quality reviews, coding education/training.
- Ability to stay abreast of coding updates, take initiative to share knowledge through official coding guidelines and coding clinics.
- Responds promptly to internal and external reviews for clarification, DRG Reviews, Business office requests or reviews for accuracy
- Identify workflow issues and promptly inform management
- Instrumental in maintaining discharged not final billed thresholds
- Advance professional growth and development through continuing education, pertinent literature, coding rounds, and seminars and other educational forums.
- Ability to review and abstract data with clear understanding of disease process, knowledgeable in identifying major complications and chronic conditions, and comprehension of present on admission. Initiate queries when appropriate
- Review medical record documentation and effectively and accurately assigns MS- APR DRG, POA, ICD-10 CM/PCS, and PSI codes to hospital inpatient records when utilizing EPIC or coding books.
- Complies with the Standards of Ethical Coding set forth by the American Health Information Management Association (AHIMA) and adheres to the official coding conventions and guidelines
- Maintain quality standards of 90% or greater while meeting or exceeding the production standards of 1 chart per hour.
- Uphold HIPAA compliance rules and regulations
Working Conditions
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This position requires: |
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Working in Office Environment |
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Working in Patient Care Unit (e.g. Nursing unit; outpatient clinic) |
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Exposure to human/animal blood, body fluids, or tissues |
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Exposure to harmful chemicals |
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Exposure to radiation |
______ No |
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Physical Demands
Indicate the time required to do each of the following physical demands:
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Time Spent |
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Never 0% |
Occasionally 1-33% |
Frequently 34-66% |
Continuously 67-100% |
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Standing |
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Walking |
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Sitting |
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Reaching |
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Lifting/Carrying |
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Up to 10 lbs |
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10lbs to 50 lbs |
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More than 50 lbs |
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Pushing/Pulling |
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Up to 10 lbs |
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10lbs to 50 lbs |
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More than 50 lbs |
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Use computer/keyboard |
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Required Education:
Associate's degree in Health Information Management, Healthcare Administration, or related healthcare field.
Preferred Education:
Bachelor's degree in Health Information Management, Healthcare Administration, or related healthcare field.
Required Experience:
Five years of clinical coding experience for complex or multi-specialties. With preferred degree, three years of clinical coding experience for complex or multi-specialties. May substitute required education degree with additional years of equivalent experience on a one to one basis.
Preferred Experience:
5 or more years of Inpatient coding experience specializing in oncology, at least 2 years auditing experience, familiar with patient safety indicators, Vizient and modality, strong communication skills.
Required Certifications/Licenses:
Required Certifications:
One or more of the following:
Registered Health Information Administrator (RHIA) by the American Health Information Management Association (AHIMA).
Registered Health Information Technician (RHIT) by the American Health Information Management Association (AHIMA).
Certified Coding Specialist (CCS) by the American Health Information Management Association (AHIMA).
Certified Coding Associate (CCA) by the American Health Information Management Association (AHIMA).
Certified Professional Coder (CPC) by the American Academy of Professional Coders (AAPC).
Certified Professional Coder - Associate (CPC-A) by the American Academy of Professional Coders (AAPC).
Certified Outpatient Coder (COC) by the American Academy of Professional Coders (AAPC).
Other Requirements:
Must pass pre-employment skills test as required and administered by Human Resources.
It is the policy of The University of Texas MD Anderson Cancer Center to provide equal employment opportunity without regard to race, color, religion, age, national origin, sex, gender, sexual orientation, gender identity/expression, disability, protected veteran status, genetic information, or any other basis protected by institutional policy or by federal, state or local laws unless such distinction is required by law. http://www.mdanderson.org/about-us/legal-and-policy/legal-statements/eeo-affirmative-action.html
