Trauma Coder

We are more than a health system. We are a belief system. We believe wellness and sickness are both part of a lifelong partnership, and that everyone could use an expert guide. We work hard, care deeply and reach further to help people uncover their own power to be healthy. We inspire hope. We learn, grow, and achieve more – in our careers and in our communities.

Job Description Summary:

This position performs coding and abstracting functions for Trauma Patients including Emergency Department, Observation, Observation in a bed and the inpatient setting.

Responsibilities And Duties:

60%
•            Assigns appropriate admit, & principal and secondary diagnoses and/or procedure codes by reading documentation present in medical record and applying knowledge of correct coding guidelines as appropriate for hospital service and/or patient type while maintaining 95% quality and meeting and maintaining the minimum Coder productivity requirements.
•            Assign Present on Admission POA indicator to all inpatient account diagnoses as required by official coding guidelines.
•            Accurately Assign ICD10 diagnosis/procedure codes, AIS scoring at the minimum standards of 95% quality and meeting and maintaining the minimum Coder productivity requirements.
Review Diagnosis and CC/MCC for maximum SOI/ROM Clinical understand of laboratory and radiology values Knowledge of quality outcomes indicators Work with CDS to improve physician documentation and case mix index Assign Principal Diagnosis accurately at least 95% or better
•            Monitor and appropriately assign codes when appropriate
•            Responsible for recognizing when it is necessary to obtain further clarification from physician when documentation is inadequate, ambiguous, or unclear for coding purposes.
•            Assists providers and supervisors with reviewing accounts denied by NTDB and other governing bodies for appropriate documentation to support original coding.

35%
•            Abstracts all data elements necessary to complete NTDB and TQIP requirements and meet hospital-reporting requirements.
•            In the event of insufficient, missing, or conflicting documentation, follows department policy for follow up and physician query.
•            Identifies problem cases in EPIC and forwards to appropriate staff for follow up.

5%
•            Verifies demographics, account number, service and identify missing or incorrect forms in each record.

The major duties, responsibilities and listed above are not intended to be all-inclusive of the duties, responsibilities and to be performed by employees in this job. Employee is expected to all perform other duties as requested by supervisor.

Minimum Qualifications:

Associate's DegreeCSTR - Certified Specialist in Trauma Registries - Registrar Certifying Board of the American Trauma Society

Additional Job Description:

SPECIALIZED KNOWLEDGE

Specialized Knowledge: AIS Scoring, ICD-10CM and PCS classification systems, Advanced Anat