Learn more about working at Beth Israel Deaconess Hospital Plymouth
MEDICAL RECORDS INPATIENT CODER/ABSTRACTOR
Plymouth, Massachusetts
Organization Facility: Beth Israel Deaconess Hospital Plymouth Category: Coding/Validation Job ID: JR57073 Date posted: 07/16/2024Job Type: Regular
Time Type: Full time
Work Shift: Day (United States of America)
FLSA Status: Non-Exempt
When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.
40hpw; Day Shift; Monday-Friday, Remote positionJob Description:
Duties/Responsibilities:
Reads patient records and, as needed, discusses patient conditions with physicians/clinical
Documentation improvement specialist to accurately and completely apply diagnostic, procedural
and service codes to each patient condition treated (including operations) during an inpatient and/
or outpatient encounter. Abstracts clinical data from the patient record and enters into computer
databases. Serves as the source of clinical data for reimbursement, planning, and research.
Competently codes/abstracts inpatient and/or outpatient records.
- Analyzes patient medical records and interprets documentation to identify all diagnoses and
procedures. Assigns proper ICD-10-CM/PCS and/or CPT diagnostic and operative procedures to
charts and related records by reference to designated coding manuals and other references
material.
- Codes and abstracts records consistently with 95% accuracy.
- Prioritizes work to ensure timely submission to billing system.
- Applies Uniform Hospital Discharge Data Set definitions to select the principal diagnosis, principalprocedure and other diagnoses and procedures which require coding, as well as other data items required to maintain the Hospital database.
- Verifies that coded information is entered into the databases without any errors.
- Applies sequencing guidelines to coded data according to official coding rules to determine the appropriate DRG assignment.
- Assesses the adequacy of medical record documentation to ensure that it supports the principaldiagnosis, principal procedure, complications and comorbid conditions assigned codes. Consults with the appropriate physician and Clinical Documentation team or appropriate parties to clarify medical record information.
- Identifies any documentation inadequacies with physician and/or appropriate parties and clarifies medical record information with courtesy and tact.
- Keeps abreast of reimbursement reporting requirements, ie: POA, medical necessity policies.
- Answers physician/clinician questions regarding coding principles, DRG assignment. Assists Finance, Data Processing and other departments with coding issues.
- Assists physicians and ancillary departments with coding questions with timeliness, courtesy and tact.
- Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members.
- Remains abreast of developments in medical record technology by pursuing a program of Professional growth and development, attending educational programs and meetings, reviewingpertinent literature and so forth.
- Utilizes professional affiliations, etc., in order to maintain current in professional developments.Attends pertinent coding seminars, when available
- Maintains updated coding books.
- Technology-Embraces technological solutions to work processes and practices.
- Safety Awareness- Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment.
It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.
Education/Experience Required:
- Associate in Science Degree in Health Information and/or Certified Coding Specialist.
- Two-three (2-3) years acute care hospital inpatient coding experience required.
- Demonstrates in depth professional knowledge of ICD-10-CM/PCS, CPT-4, medical terminology, anatomy and physiology and DRG assignment.
- Knowledge of MCR, MCD and 3rd Party coding requirements, including MS-DRGs, APR-DRGs and AP DRGS.
- Successful passage of HIM Department Inpatient Coding Examination with grade of 80% or higher.
- Detail oriented with strong interpersonal and organizational skills.
- Strong computer skills with a good working knowledge of 3M coding software and Meditech Abstracting preferred.
Registration/Certification:
- CCS, CCS-P, CPC, or CPC-H
- Registered Health Information Technician (RHIT), preferred, not required.
- Registered Health Information Administrator (RHIA), preferred, not required.
As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more about this requirement.
More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.
Equal Opportunity Employer/Veterans/Disabled
Related Jobs
-
-
-
-
-
Check out Benefits at BILH
Discover the outstanding BILH benefits that await you, encompassing competitive compensation packages, healthcare coverage, and a range of wellness programs designed to support your overall well-being.
-
-
-
-
-
-
-
-
-
Learn more about Nursing at BILH
Explore the diverse and rewarding nursing opportunities at BILH, where you can make a meaningful impact on patient care while growing your skills in a supportive and innovative healthcare environment.
-
New Grad and Newly Licensed Nursing Program
As new grad or newly licensed RN, explore the rotational programs at our hospitals.
-
Learn more about Nursing at BILH
Explore the diverse and rewarding nursing opportunities at BILH, where you can make a meaningful impact on patient care while growing your skills in a supportive and innovative healthcare environment.
-
Explore Upcoming Events
Stay informed and engaged by exploring the upcoming BILH events, where you'll have the opportunity to connect with colleagues, expand your professional network, and gain insights into the latest advancements and trends in healthcare.
-
Learn more about Operating Room roles at BILH
Explore the many Operating Room nurse and surgical tech opportunities at BILH, where you can make a meaningful impact on patient care while growing your skills in a supportive and innovative healthcare environment.
-
-
Explore open positions within our Radiology Team at BILH!
Beth Israel Lahey Health has multiple opportunities to join the Radiology team. Join a work place that strives for excellence!
-
-
Why join Beth Israel Lahey Health?
If you’re looking for a career where you can make a difference and explore your potential, Beth Israel Lahey Health is the place you belong. Our system includes a network of hospitals, physician practices, outpatient centers, and other healthcare facilities and we offer a broad range of careers in direct patient care, environmental services, registration, finance and many other fields. We are focused on providing compassionate and personalized healthcare with a strong reputation for clinical excellence and research and offer diverse opportunities for career growth and development. Conveniently, we have many locations in communities across Eastern Massachusetts and Southern New Hampshire.
At Beth Israel Lahey Health, we see you for all that you are – your experience and your dreams. Explore our open opportunities and find out why so many have already chosen to join our team.
View All Opportunities![](http://tbcdn.talentbrew.com/company/169/gst_v1_0/img/why-join-image-updated-01-v1.jpg)
![](http://tbcdn.talentbrew.com/company/169/gettyimages-501926079-desktop.jpg)
![](http://tbcdn.talentbrew.com/company/169/gettyimages-501926079-mobile.jpg)