Inpatient Coder II Medical Records Full Time Days

Desert Regional Medical Center is a 385-bed acute-care hospital classified as a stroke receiving center and level 2 trauma facility with an innovative, patient centered and evidence-based Rehabilitation Services Department.  Our compassionate team provides a wide range of inpatient and outpatient services, including acute care rehabilitation, joint replacement & spinal surgery, neurosurgery, ICU, Telemetry, step-down care, skilled nursing, as well as outpatient therapy, hand and lymphedema clinics. 

GENERAL DUTIES:

The Coder II is responsible for accurate coding and abstracting of clinical information from the medical record.  The position is responsible for maintaining Tenet standards for coding data quality and integrity, as well as productivity within established guidelines.  The Coder II is responsible for coding of Tenet facilities as assigned, assisting with productive coding to maintain DNFC, and assisting with the training of new coders, resolving coding edits, CARDS edits and/or other projects.

The Coder II codes and abstracts Ancillary, Emergency Department, Outpatient Surgery, Observation, or low acuity Inpatient encounters according to the Tenet Coding Quality Standards policy/procedure.  Coding function includes diagnosis, PCS, CPT, HCPCS, modifiers, CARDS and coding edit resolution.

Meets Coding and Abstracting Productivity Expectations set by Tenet Standards/Policy

 

Shift: Days

Days off: 

DEPARTMENT SPECIFIC DUTIES:

1. Complies with established departmental policies and procedures, objectives, safety, environmental and infection control standards.
2. Cooperates with other personnel to achieve department objectives and maintain good employee relations.
3. Consistently demonstrates a professional and proactive attitude and actions in all interfaces with employees, hospital staff and physicians as well as patients.
4. Provides for privacy and patient/employee dignity by maintaining employee/patient and departmental confidentiality with no infractions.
5. Codes and abstracts all medical records for the purpose of reimbursement and research.  Coding complies with federal regulations according to diagnoses, operations and procedures using ICD-10-CM, ICD-10-PCS, and CPT codes.
6. Accurately codes Ancillary, Emergency Department, Outpatient Surgery, Observation, or low acuity Inpatient encounters according to the Tenet Coding Quality Standards policy/procedure. Daily assures that all codes are entered into appropriate database on a daily basis
7. Reviews monitoring reports to assure that there are no outstanding accounts awaiting final diagnosis.
8. Serves as a liaison between medical records and the business offices of the hospital and the physician offices regarding any coding questions or discrepancies.
9. Assists in training in coding.
10. Responsible for continuing education and completion of lessons in LearnShare
11. Is always responsible for the maintenance of timely coding.
12. Performs other related duties as assigned or requested.
13. Understands HIPAA, privacy and confidentiality and demonstrates minimum necessary standard according to position

Minimum Education:                     

• High School Diploma or GED equivalent 
• Completion of coding certificate program or associates or bachelor’s degree in health information management or related field

Minimum Experience:                   

• 2-5 years facility-based coding

Preferred:                                          

• RHIT, CCS, and/or RHIA

Skills-Machines: Computer and phones

Skills-Administrative: Working knowledge of MS Office Suite, electronic medical record, and encoder

Conditions: Remote Office Setting  

 

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Tenet complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

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