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Coding Specialist II, Onsite Role

Location: Clackamas, Oregon;

Job ID : 543740


To provide expertise at an advanced level of Clinical Data Specialist I, in collection, interpretation, and analysis of patient healthcare information, ensuring the quality of medical records by verifying their completeness, accuracy, and proper entry into computer systems, specializing in coding diagnoses and procedures for reimbursement and research.

Essential Responsibilities:
  • Under minimal supervision responsible for medical record review and translating clinical information into coded data, utilizes an Encoder software system, analyzing and maintaining its accuracy, validity, and meaningfulness. Utilizes electronic patient data system and clinical information system (EpicCare) to access patient encounter information. Abstracts and enters clinical data elements as defined by the needs of the organization for patient utilization/outcome studies, financial information, research, reimbursement, and governing agencies. Identifies and assigns principal diagnosis and procedure codes, sequencing them as appropriate by following the Uniform Hospital Discharge Data Set (UHDDS), and adhering to standards of billing set by Medicare (HCFA), Medicaid (OMAP), and other intermediaries to enable capture all documented medical services. Routinely performs chart analysis to identify areas of the medical record that contain incomplete, inaccurate or inconsistent documentation. Reviews and verifies chart information (i.e. POS, attending provider) Assesses and inputs data. Reviews and verifies component parts of medical records to ensure completeness and accuracy of diagnostic and therapeutic procedures that must conform to CMS coding rules and guidelines.
  • Fully utilizes resources available such as 3M encoder product, internet medical sites, Coding Clinic and CPT Assistant to research issues to apply coding guidelines for ICD-10, CPT and HCPCS codes. Using knowledge of coding guidelines and reimbursement reporting requirements; identifies concerns and informs supervisors/managers as appropriate. Working knowledge of APC/MS-DRG/APR-DRG.
  • Reviews bulletins, newsletters and periodicals and attends workshops to stay abreast of current issues, trends, and changes in the laws and regulations governing medical record coding and documentation to mitigate the risk of fraud and abuse and to optimize revenue recovery. Review Annual ICD-10 Official Guidelines for Coding, along with review of quarterly Coding Clinic and monthly CPT Assistant and identify implications to current coding process. May assist other level coders with special projects. Utilizes query process when appropriate. Performs as a team member of Coding and Documentation Services and actively participates with peers in coding in-services, staff meetings, reporting of performance measures, and quality outcome monitors. May participate in mentoring new hires to the department. Completes other tasks as assigned.

    Qualifications: Basic Qualifications:
  • Minimum two (2) years of coding experience in assignment of diagnostic and procedural coding.
  • High School Diploma or General Education Development (GED) required with current credential with AHIMA.
    License, Certification, Registration
  • Register Health Information Administrator (RHIA), OR
  • Registered Health Information Technician (RHIT), OR
  • Certified Coding Specialist (CCS) from AHIMA, OR
  • Certified Professional Coder (CPC) actively pursuing a Certified Coding Specialist (CCS) and to be obtain within 18 months of hire date.
  • Certified Professional Coder (CPC) actively pursuing a Registered Health Information Technician (RHIT) and to be obtain within 2 years of hire date.

    Additional Requirements:
  • Previous experience with EMR patient documentation system with knowledge and skill in the use of a computer.
  • Thorough knowledge of disease processes, diagnostic and surgical procedures, ICD-10, CPT, HCPCS classification systems, and health information/medical record department responsibilities with awareness of government regulations and potential areas of risk for fraud and abuse issues.
  • Thorough knowledge of medical terminology, pharmacology and medical coding principles for ICD-10, CPT and HCPCS coding.
  • Fluent in English demonstrating skill and proficiency in oral and written communication.
  • Skill in time management, organization and analytical skills.
  • Ability to manage a significant work-load and to work efficiently under pressure meeting established deadlines with minimal supervision.
  • Ability to use independent thought and judgment regarding code selection and to easily adapt to unfamiliar automated systems.
  • Demonstrates customer-focused service skills.
  • Abides by the Standards of Ethical Coding as set forth by AHIMA.
  • Meets department standards for performance and quality - all medical coders must maintain 95% accuracy on all assignments for 3 consecutive months.
  • Final candidates will be required to obtain 75% or better on Kaiser Coding Skills Assessment for Coder II.
  • Academic knowledge and working experience performing coding and abstracting responsibilities in health information/medical record services.
  • Ability to work at a level of production and accuracy above or equivalent to Clinical Data Specialist I.

    Preferred Qualifications:
  • Minimum three (3) years of coding experience health information/medical record environment that includes Medicare reimbursement guidelines.
  • Advanced experience in the use of a computer and related systems and software to include: EMR(s), Microsoft Office Suite and other software programs.
  • Ability to understand, evaluate and contribute to math concepts regarding statistics and percentages that compare findings, trends, outcomes related to productivity and/or medical record audits.
  • Knowledge and demonstrated understanding of CMS HCC Risk Adjustment coding and data validation requirements preferred.

  • Associate degree in health information technology from an accredited program

    Primary Location:Oregon,Clackamas,Regional Process Center 10220 SE Sunnyside Rd.

    Scheduled Hours (1-40):40


    Working Days:Mon - Fri


    Job Type:Standard

    Employee Status:Regular

    Employee Group:Non-Union, Non-Exempt

    Job Level:Individual Contributor

    Job:Medical Records

    Public Department Name:Facility Documentation & Coding Services

    External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with Federal, state and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran, or disability status.
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