Inpatient Coder 3 (H)

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The University of Miami/UHealth Department of Health Information Management has an exciting opportunity for a full-time Inpatient Coder III to work remotely. Under the general direction of the Inpatient Coding Manager, the Inpatient Coder III reviews documentation in the electronic medical record (EMR) and assigns and sequences ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes in accordance with national coding guidelines. The primary focus of this role is to capture all encounter specific diagnoses and procedure codes for accurate reimbursement, data collection, and research purposes.

CORE JOB FUNCTIONS                                                                                                          

• Review, analyze, and interpret the entire electronic medical record (EMR) to identify all diagnoses and procedures documented during a patient’s admission.

• Determine and assign the principal diagnosis and all significant secondary ICD-10-CM diagnosis codes, in addition to Present on Admission (POA) indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, medical terminology, and disease processes.

• Identify cases with clinical indicators that require provider documentation, clarification, and/or specificity to accurately assign codes; collaborate with the Clinical Care Transformation (CDI) team as part of the clinical documentation validation and physician query workflow.

• Analyze and sequence codes in compliance with ICD-10 official coding guidelines, Uniform Hospital Discharge Data Set (UHDDS), and other regulatory requirements to assure proper Medicare Severity Diagnostic Related Groups (MS-DRG) assignment.

• Review medical record documentation for major complications and comorbidities (MCC), complications and comorbidities (CC), severity of illness (SOI) and risk of mortality (ROM).

• Consistently maintain coding accuracy and productivity standards of ≥ 95%.

• Adheres to University and unit-level policies and procedures and safeguards University assets.

Department Specific Functions

• Sign into Microsoft Teams for quick and easy communication between management, supervisors, and colleagues.

• Review Inpatient Priority work queue each morning to rectify any accounts that have been returned due to missing documentation, physician query response, DRG mismatch, etc.

• Mandatory daily review and reconciliation of any pending audit reviews.

• Code any high dollar accounts that have been assigned by the coding supervisor or manager.

• Check IP Uncoded Cardiovascular Special Procedures work queue and code any charts that are available.

• Review IP Uncoded Interim work queue for any new or returning accounts ready to be coded.

• Move to the HIM-IP Uncoded Inpatient & Hospice work queue, where charts are assigned to the coder by oldest discharge date and highest dollar utilizing the get next feature.

• Work claim edits and review accounts from hospital billing.

• Assist with the payor denial process.

• Check email often for any correspondence coming from IP coding supervisor/manager, CDI, IT, ect.

• Attend all scheduled one on one meetings and/or team meetings.

• Participate in team provided education sessions as well as any AHIMA/AAPC approved continuing education courses to maintain credentials.

This list of duties and responsibilities is not intended to be all-inclusive and may be expanded to include other duties or responsibilities as necessary.

CORE QUALIFICATIONS                                                                                                         

• High School Diploma or equivalent

• Graduate of an accredited Health Information Technology or Coding program.

• Minimum 5+ years of current ICD-10-CM/PCS acute care facility coding experience required.

• Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), &/or Regist