Coder 2 ED/Emergency

Mark Twain Medical Center is a member of Dignity Health. The word “dignity” perfectly defines what our organization stands for, showing respect for all people by providing excellent care. Mark Twain Medical Center opened on August 26, 1951 and is located in beautiful San Andreas California. Since opening, Mark Twain has provided the highest quality health care for all those needing medical care in Calaveras County. We offer caring, expert staff and state-of-the-art equipment to meet the growing needs of our community and are commitment to the values of dignity, collaboration ,justice, stewardships and excellence.

Position Summary:

The Coder II is a member of the Health Information Management Team responsible for ensuring the accuracy and completeness of clinical coding, validating the information in the databases for outcome management and specialty registries, across the entire integrated healthcare system. The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual patient health information records for data retrieval, analysis and claims processing. This position is expected to perform duties in alignment with the mission and policies within the Dignity Health organization, TJC, CMS, and other regulatory agencies.

Principle Duties and Accountabilities:

• Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system for ED admissions.
• Can code ancillary charts if needed.
• Review provider documentation to determine the reason for visit, first listed and secondary diagnosis codes and surgical procedures following official coding guidelines.
• Provide documentation feedback to providers, as needed
• Utilize technical coding principals and APC reimbursement expertise to assign appropriate ICD-10-CM diagnoses and CPT codes for procedures.
• Extract required information from source documentation and enter into encoder and abstracting system.
• Review documentation to verify and when necessary, correct the patient disposition upon discharge.
• Prioritize work to ensure the timeframe of medical record coding meets established KPI's.
• Serve as a resource for coding related· questions as appropriate.
• Meet performance and quality standards at the Coder I level.
• Participate in department meetings and educational events.
• Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
• Assists with OSHPD correction.
• Other duties as assigned that have a direct impact on our ability to decrease the DNFB and support Revenue Cycle, including but not limited to charge validation, observation calculations, etc..

Minimum Qualifications:

• High School Diploma or equivalent.
• Completion of an AHIMA or APPC accredited coding certification program that includes courses that are critical to coding success such as Anatomy and physiology, pathophysiology, pharmacology, Anatomy I Physiology, Medical Terminology, and ICD-10 and CPT coding courses, etc..
• Have and maintain current coding credential from AHIMA or AAPC (RHIA, RHIT, CCS, CCS-P, CPC, or CPC-H ).
• Two years of coding and abstracting experience or an equivalent combination of education and experience required.
• A minimum of 2 years Emergency and Ancillary facility coding experience*.
• Must have ICD-10 coding experience.
• Ability to use a PC in a Windows environment, including MS Word and EMR systems.
• Ability to pass coding technical assessment.
  
  *One year of experience will be waived for those who have attended the Dignity Health Coding Apprenticeship Program.* 

Preferred Qualifications:

• Experience with various Encoder systems (i.e., OptumCAC, Cemer).
• Intermediate level of Microsoft Excel.
• Experience with coding and charge validation.

This position is an on-site position, remote work option is not available.