HIM Surgery Coder

This is a fully remote position.

Job Description

Applies knowledge of anatomy and physiology, medical terminology and pathology of disease processes while analyzing clinical documentation for inpatient and outpatient records for facility and/or professional services coding. May be assigned to work edit lists for accuracy of claims processing and data reporting. Applies knowledge of ICD-10 and CPT-4 nomenclatures and American Hospital Association, American Medical Association and applicable Federal and third party payer guidelines to accurately and compliantly determine principal and secondary ICD-10 diagnoses codes, principal and secondary ICD-10 procedure codes for all visits. In addition, assigns corresponding CPT-4 codes for all inpatient surgery cases or outpatient CPT defined procedural services for facility and professional billing and assignment of appropriate modifiers. Appropriately assigns ICD- 10 codes for professional services per medical necessity criteria. Follows UVMMC compliance and HIM coding compliance policies and by maintaining financial goals and meeting or exceeding accuracy and productivity standards. Utilizes various electronic information systems to accomplish coding including, EPIC, 3M/Solventum Coding and Reimbursement Systems, NCCI edit software, EncoderPro, and other clinical documentation systems or reference systems as deemed appropriate. Must have knowledge of charge master and charge maintenance. Effectively communicates with and acts as a resource to health care providers, department managers and staff to resolve documentation, charge or other issues as they arise to ensure accuracy of coding and reimbursement. HIM Coder Staff may be assigned other duties as deemed necessary by the HIM Supervisor and or HIM Manager. HIM Coder Staff will adhere to the HIM Mission and Vision. All coders will continually seek to improve coding knowledge through various mediums including seminars, articles, networking, web access and other as available.

Education

Minimum: High school diploma. College level Anatomy and Physiology and Medical Terminology required. Associate's degree or Bachelor's degree in Allied Health or HIM preferred.

AHIMA or AAPC certification (above an associate level) and as a condition of continued employment, must maintain certification status and CEU’s. If an employee has a lapse in certification, they shall have six months for first attempt to become recertified. If unable to become recertified within the year, may be demoted to the HIM Associate Level. Recertification is at the expense of the employee. An employee who is demoted due to a lapse in certification will be placed back at their current level (staff or senior) upon recertification.

Experience

Two years of Coding in a university hospital or professional setting or two years of coding as a UVMMC, HIM Coder or MGC Coder. Coding or billing experience preferred, utilizing ICD-10-CM, CPT-4, HCPCS level II and/or experience performing clinical documentation record reviews.

Demonstrated ability meet or exceed quality and productivity standards.