New Hanover Regional Medical Center
New Hanover Regional Medical Center in Wilmington, NC offers many career opportunities for those who have a passion for making a positive difference in the lives of others. As the largest healthcare provider in the region, we are an Equal Opportunity Employer employing almost 7,000 people. Where you work has a big impact on your life. It should be professionally and personally rewarding. At New Hanover Regional Medical Center, we recognize recruiting and retaining the best takes a commitment to providing benefits that support you and your family’s well-being. We offer generous health and wellness benefits as well as support for education and career advancement.
Under the general direction of the Coding and Clinical Abstracting Manager, this specialist is responsible for accurate coding of diagnosis and procedures and DRG assignment for all inpatient records, He/She assigns codes from appropriate documentation in the medical record of the patient using appropriate code set classification systems including ICD-9-CM/PCS, ICD-10-CM/PCS, and CPT. The Coding Specialist IV communicates with physicians and professional staff including nursing and clinical documentation specialists to obtain clarification so that the medical record portrays an accurate clinical picture of the care delivered and supports compliant code assignment and reimbursement. This professional is skilled in writing compliant post discharge queries when needed to clarify documentation in accordance with facility guidelines. He/She is responsible for monitoring the Discharges Not Final Billed (DNFB) list, CFB days, and Case Mix Index, and plays an active role in meeting the organization’s revenue cycle goals. This specialist possesses an in-depth understanding of clinical indicators, disease processes, DRG reimbursement, Hospital Acquired conditions, PSI’s, and CC/MCC payment impacts. This individual requires little supervision and performs all work independently, with a high degree of autonomy. All work is carried out in accordance with the department’s approved policies and procedures and in compliance with coding guidelines and standards of ethical coding.
1. Accurately codes all diagnoses and procedures and assigns the appropriate DRG for all inpatient encounters according to the appropriate classification system and in accordance with provisions of the Uniform Hospital Discharge Data Set as well as coding guidelines and all governmental and private Third Party rules and regulations.
2. Abstracts patient information from records of all assigned accounts and enters appropriate data elements into the computerized abstracting system.
3. Works with Coding Auditors, Clinical Documentation Specialists, and clinicians to identify areas for improvement in documentation and collaborates on educational initiatives regarding documentation and DRG assignment.
4. Consistently meets coding productivity target (100%) and accuracy requirements (95% or higher).
5. Communicates with physicians and professional staff including nursing and CDI specialists to obtain clarification, including writing compliant post discharge queries, so that the medical record portrays an accurate clinical picture of the care delivered and supports compliant code assignment and reimbursement.
6. Prepares workload reports and plays an active role in meeting the departmental and organizational revenue cycle goals.
7. Promotes customer satisfaction through prompt and courteous service.
8. Fosters respect for patient privacy by maintaining confidentiality in all phases of work.
9. Completes continuing education required to maintain credential.
10. Performs those duties necessary to ensure all accounts are processed accurately and timely.
11. Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
12. Performs other duties as assigned.
All the primary duties within this document will be performed according to established policies, procedures and guidelines within the department and the Medical Center.
This position has access to and knowledge of extremely sensitive, private and confidential materials. Ability to maintain the highest standard is required with zero tolerance.
- Three-Five years in coding/abstracting using ICD-9-CM/PCS, ICD-10-CM/PCS and CPT-4 in an acute care hospital based setting required.
- Extensive knowledge of ICD-9-CM/PCS, ICD-10-CM/PCS and CPT coding required
- Advanced medical terminology, clinical medical concepts, and human anatomy and physiology required. Education may be through formal programs of study or through sequenced in-service training.
- Licensure / Certifications: AHIMA credentialed Certified Coding Specialist (CCS) strongly preferred, RHIT, RHIA or other coding credential preferred.
- Inpatient coding and DRG assignment experience preferred.
- High School Diploma required. B.S degree or A.A. degree in Health Information Management or Nursing preferred.