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Exemption Status:

Non-Exempt

Schedule Details:

Monday through Friday

Scheduled Hours:

7-3:30

Shift:

1 - Day Shift, 8 Hours (United States of America)

Hours:

40

Cost Center:

99940 - 5458 Coding Services

Union:

SHARE (State Healthcare and Research Employees)

This position may have a signing bonus available a member of the Recruitment Team will confirm eligibility during the interview process.

Everyone Is a Caregiver

At UMass Memorial Health, everyone is a caregiver – regardless of their title or responsibilities. Exceptional patient care, academic excellence and leading-edge research make UMass Memorial the premier health system of Central Massachusetts, and a place where we can help you build the career you deserve. We are more than 20,000 employees, working together as one health system in a relentless pursuit of healing for our patients, community and each other. And everyone, in their own unique way, plays an important part, every day.

Interprets a wide variety of clinical and diagnostic documentation, including complex medical cases and treatments, to identify: diagnoses, complications, comorbidities, and procedures associated with episodes of inpatient care. Assigns appropriate Diagnosis Related Group (DRG) to each coded inpatient account to obtain optimal hospital reimbursement, Severity of Illness (SOI), and Risk of Mortality (ROM). Assigns current edition of ICD-CM, ICD-PCS, and CPT codes as appropriate adhering to official coding guidelines.

I. Major Responsibilities: 

1. Upon review of the medical record, performs analysis on documentation, which includes: History & Physical (H&P), progress notes, flow sheets, Provider orders, consultations, operative reports, pathology results, and additional tests / reports to determine the appropriate current edition ICD-CM diagnosis and ICD-PCS codes as defined by official coding guidelines, the Coding Clinic, and other recognized reference materials. 
2. Reviews clinical documentation to ensure accurate discharge disposition is assigned and notifies Manager when clarification is needed.
3. Assigns the correct principal diagnosis, comorbidities and complications (CCs), secondary diagnoses, POA (Present on Admission) indicators, HAC (Hospital-Acquired Conditions), principal procedure codes, and secondary procedure codes according to official coding guidelines, the Coding Clinic, and in accordance with all official Uniform Hospital Discharge Data Set (UHDDS) definitions.
4. Based upon the assigned codes, utilizes the computerized 3M Encoder software to assign the most accurate DRG. 
5. Initiates the retrospective query process when documentation is inconsistent, incomplete, ambiguous, or non-specific. 
6. Works closely with the Clinical Documentation Improvement (CDI) Program, Retrospective CDIS Nurse, or Manager to improve medical record documentation.
7. Assists in resolving incomplete and / or missing chart documentation in order to expedite coding and billing.
8. Participates in the continuous coding audit and performance management program. 
9. Maintains DRG and coding accuracy rate of not less than 95% for optimal reimbursement as well as department productivity standards as outlined in department policies.
10. Attends required training classes and coding in-services each year to stay abreast of new regulations and coding guidelines. 
11. Participates in improvement efforts and documentation training for medical and clinical staff as it relates to coding practices and guidelines.
12. Communicates to direct Manager when backlog situations arise or necessary documents are either incorrect or are not being received in a timely manner. 
13. Refers all unusual, questionable situations to the Inpatient Coder Lead or Supervisor of Inpatient Coding. Alerts management to any coding irregularities, or trends contrary to policies and procedures, so corrective measures may be taken.
14. Adheres to the coding and billing regulations established by the American Hospital Association (AHA), American Medical Association (AMA), and Centers for Medicare and Medicaid Services (CMS). 
15. Maintains direct and ongoing communications with other coding personnel to maximize overall effectiveness and efficiency of the operation.
16. Keeps current with all coding updates and information related to correct coding.

Standard Staffing Level Responsibiliti