Inpatient Coder

DESCRIPTION OF POSITION

This job description is a record of the essential functions of the listed job. The job description provides the employee, CEO, Human Resources, applicants, and other agencies with a clear understanding of the job, where it fits into the organization, and the skill and work requirements in relation to other jobs. Jobs are always changing to some degree and the existence of the approved job description is not intended to limit normal change and growth. The facility will make reasonable accommodations to otherwise qualified individuals who are capable of performing the essential functions of the job with or without reasonable accommodation.

POPULATION SERVED

The position involves no direct patient care for a population of patients ages 18 and older. Age specific experience and/or special training and/or expertise are not required.

POSITION SUMMARY

The Inpatient Coder is responsible for admissions, concurrent and discharge coding; assembling of medical records; analyzing records (flagging deficiencies). The Inpatient Coder must thoroughly review all patient medical charts in an effort to ensure accuracy of information.

POSITION QUALIFICATIONS

The position requires a minimum of a High School Diploma, an Associate’s Degree preferred, Certified Coding Associate (CCA) or Certified Coding Specialist (CCS) certificates preferred and a minimum of one (1) year of experience in Long Term Acute Care Coding and Medical Records Preferred. Good interpersonal skills are very important.

DUTIES AND RESPONSIBILITIES

• Reviews and codes inpatient and/or outpatient medical information
• Compiles statistics and prepares/maintains a variety of records and reports; finalizes attending physicians’ attestations and obtains signatures; researches and locates missing data and records needed for coding and abstracting.
• Retrieve patient records for doctors and nurses for future diagnosis and treatment.
• Keep track of medical records to document improvement or deterioration in condition.
• Processes the admission and discharge paperwork.
• Serve as liaisons between the provider and the billing office.
• May perform additional administrative duties and other duties as assigned by supervisor.

DEMANDS AND CHARACTERISTICS OF WORK, EQUIPMENT USAGE, AND WORK ENVIRONMENT.

PERCENTAGE OF WORK TIME

1. Standing/Walking: 34-66%
2. Sitting: 1-33%
3. Twisting: 1-33%
4. Lifting/Carrying: 1-33%
5. Pushing/Pulling: 1-33%
6. Climbing (Ascending/descending): 1-33%
7. Bending/Stooping: 1-33%
8. Using arm muscles frequently or for extended periods: 1-33%
9. Using leg muscles frequently or for extended periods: 1-33%
10. Using back muscles frequently or for extended periods: 1-33%

LIFTING REQUIREMENTS – Individuals in patient care positions are required to lift a patient with or without assistance.

1. 2-10 Pounds: 1-33%
2. 11-20 Pounds: 1-33%
3. 21-30 Pounds: 1-33%
4. 31-40 Pounds: 1-33%
5. 41-50 Pounds: 1-33%
6. 51 Pounds or More: 1-33%

WORKING ENVIRONMENT

1. Working in hot, cold, wet surroundings: 1-33%
2. Working outdoors: 1-33%
3. Working with or near chemicals: 1-33%
4. Working near radiation sources: 1-33%
5. Potential exposure to communicable diseases: 1-33%
6. Working with hazardous waste materials: 1-33%
7. Utilizing essential upgraded or adaptive equipment as industry standards require: 1-33%
8. Using hand tools: 1-33%
9. Operating vehicle: 1-33%
10. Potential for cuts and bruises: 1-33%

EXCHANGE OF IDEAS

1. Ability to express or exchange ideas: 67-100%
2. Ability to understand communication of others with or without adaptive devices: 67-100%
3. Ability to perform secondary math: 67-100%
4. Ability to read at a secondary level: 67-100%

WORKPLACE BEHAVIORS

• RESULTS ORIENTATION – Meets current objectives and positions the organization for future growth. Completes daily tasks and assignments and processes large volumes of work associated with the operation of the department.
• SOCIAL SENSITIVITY - Builds positive relationships based on respect for others. Demonstrates a helpful, positive attitude. Maintains effective communication with pees, medical staff, patients, visitors, and families.
• QUALITY OUTCOMES – Meets and exceeds expectations of internal and external customers. All organizational and departmental standards regarding quality of performance are met. Demonstrates a strong commitment to confidentiality. Participates in quality improvement programs as directed.
• SAFE WORKING ENVIRONMENT – Demonstrates an awareness of and adherence to safety and legal requirements established at the facility with an emphasis on maintaining a safe environment for all persons working in the facility.
• Accident/Injury Reporting – Reports any accidents, injuries, and unsafe equipment and conditions to supervisor by the end of the shift and reports any pre-existing conditions as identified by the ADA.
• Unsafe Conditions – Immediately reports and corrects, if possible, unsafe conditions or equipment.
• Workplace Standards – Compiles with relevant regulations, standards and policies governing safe workplace environment (OSHA, Accreditation, etc.)
• Safety Techniques – Maintains current knowledge of all aspects of the facility’s safety program by attending safety-related training as mandated upon hire and thereafter as required by facility.
• Modified Work – Accepts modified work assignments after receiving the physician’s release to return to work following an accident/ injury.
• Follows Prescribed/Recommended Treatment – Follows the prescribed/recommended treatment given by treating physician(s) after an accident/injury.
• EDUCATION – Participates in required inservice and educational programs on an ongoing basis.
• ATTENDANCE AND PUNCTUALITY – Follows all facility guidelines outlining standards of attendance and punctuality. Responsible for reporting to and completing work at assigned times.

UNIVERSAL PRECAUTIONS

Universal precautions will be observed in order to prevent contact with blood or other potentially infectious materials. Under circumstances in which differentiation between body fluid types is difficult or impossible, all body fluids shall be considered potentially infectious materials. All blood or other potentially infectious materials will be considered infectious regardless of the status. The category shown below is designed to communicate the risk of exposure for this particular position.

Category I

Tasks involve light contact with moist body substances, non-intact skin or mucous membranes. Department procedures define and require use of minimum protective measures to perform the task.

Category II

Tasks involve no contact with moist body substances, non-intact skin or mucous membranes; however, employment may require performing unplanned Category I task. Appropriate protective measures are readily available.

Category III

Tasks of employment involve no contact with moist body substance, non-intact skin or mucous membranes.