University of Utah Health·Salt Lake City, Utah
The specialist performs thorough medical record reviews to identify and assign accurate ICD-CM and ICD-10 PCS codes for inpatient facility coding. They also provide clinical documentation improvement support and collaborate with clinical staff to ensure compliant provider query practices.
Overview As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education.
Success in this mission requires a culture of collaboration, excellence, leadership, and respect.
University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, integrity, quality and trust that are integral to our mission.
EO/AA This position provides inpatient facility coding and Clinical Documentation Improvement (CDI) support in Health Information Management department with minimal educational intervention required.
The incumbent must abide by hospital, state and federal coding guidelines established by DNV, the American Hospital Coding Association, and Medicare/Medicaid, etc.
Corporate Overview: The University of Utah is a Level 1 Trauma Center and is nationally ranked and recognized for our academic research, quality standards and overall patient experience.
Our five hospitals and eleven clinics provide excellence in our comprehensive services, medical advancement, and overall patient outcomes.
Essential Functions Perform thorough review of medical record for identification of relevant clinical diagnoses and procedures performed. Assign appropriate ICD-CM principal diagnosis code. Assign appropriate ICD-CM secondary diagnosis codes. Assign appropriate ICD-10 PCS code(s). Sequence principal and secondary diagnoses codes and primary procedure code for accurate MS-DRG and APR-DRG assignment. Assign Present on Admission (POA) indicator for each diagnosis code. Abstract required data elements, including but not limited to: Admit Type, Admit Source / Point of Origin, and Discharge Disposition. Identification of opportunities where additional provider documentation is required to thoroughly and accurately assign ICD-10 code. Understand and adhere to compliant provider query practices and procedures. Understand and adhere to Health Information Coding policies and Official Coding Guidelines, as published by CMS and Cooperating Parties. Knowledge / Skills / Abilities Proficient knowledge of medical terminology, anatomy & physiology and pathophysiology. Proficient knowledge of coding conventions & use of coding nomenclature. Proficient in all service lines of varying complexity. Working knowledge of health care quality related initiatives. Achieve and sustain acceptable productivity rate as defined by Coding Leadership. Ability to effectively communicate with clinical staff and other hospital department personnel. Knowledge of healthcare IT systems, preferably Epic and 3M 360 Encompass R2. Knowledge of Microsoft Office. Team player, ability to collaborate with colleagues and leadership. Ability to effectively mentor entry-level staff.
Candidates must have at least four years of inpatient facility coding experience and hold a current RHIA, RHIT, or CCS certification. Proficiency in medical terminology, coding conventions, and healthcare IT systems like Epic is required.
Market context
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