Trauma Coder

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Job Description Summary

This position performs coding and abstracting functions for Trauma Patients including Emergency Department, Observation, Observation in a bed and the inpatient setting.

Responsibilities And Duties

60%

• Assigns appropriate admit, & principal and secondary diagnoses and/or procedure codes by reading documentation present in medical record and applying knowledge of correct coding guidelines as appropriate for hospital service and/or patient type while maintaining 95% quality and meeting
  
  

and maintaining the minimum Coder productivity requirements.

• Assign Present on Admission POA indicator to all inpatient account diagnoses as required by official coding guidelines.
• Accurately Assign ICD10 diagnosis/procedure codes, AIS scoring at the minimum standards of 95% quality and meeting and maintaining the minimum Coder productivity requirements.
  
  

Review Diagnosis and CC/MCC for maximum SOI/ROM Clinical understand of laboratory and radiology values Knowledge of quality outcomes indicators Work with CDS to improve physician documentation and case mix index Assign Principal Diagnosis accurately at least 95% or better

• Monitor and appropriately assign codes when appropriate
• Responsible for recognizing when it is necessary to obtain further clarification from physician when documentation is inadequate, ambiguous, or unclear for coding purposes.
• Assists providers and supervisors with reviewing accounts denied by NTDB and other governing bodies for appropriate documentation to support original coding.
  
  

35%

• Abstracts all data elements necessary to complete NTDB and TQIP requirements and meet hospital-reporting requirements.
• In the event of insufficient, missing, or conflicting documentation, follows department policy for follow up and physician query.
• Identifies problem cases in EPIC and forwards to appropriate staff for follow up.
  
  

5%

• Verifies demographics, account number, service and identify missing or incorrect forms in each record.
  
  

The major duties, responsibilities and listed above are not intended to be all-inclusive of the duties, responsibilities and to be performed by employees in this job. Employee is expected to all perform other duties as requested by supervisor.

Minimum Qualifications

Additional Job Description:

SPECIALIZED KNOWLEDGE

Associate's degree or 1-3 years of coding experience in an acute care/hospital setting.

Specialized Knowledge: AIS Scoring, ICD-10CM and PCS classification systems, Advanced Anatomy & Physiology, Pathophysiology, Pharmacology, Medical Terminology, inpatient documentation schemes. Knowledge of Hospital Acquired Conditions (HAC), Present on Admission (POA), Severity of Illness (SOI), Risk of Mortality (ROM), and Quality outcome indicators. Knowledge of operative reports, clinical lab, and radiology results for physician queries. Knowledge of Clinical Documentation improvement programs. Knowledge of NTDB and TQIP abstracting elements.

Work Shift

Day

Scheduled Weekly Hours

40

Department

Trauma Services

Join us!

• if your passion is to work in a caring environment
• if you believe that learning is a life-long process
• if you strive for excellence and want to be among the best in the healthcare industry
  
  

Equal Employment Opportunity

OhioHealth is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations. OhioHealth does not discriminate against associates or applicants because of race, color, genetic information, religion, sex, sexual orientation, gender identity or expression, age, ancestry, national origin, veteran status, military status, pregnancy, disability, marital status, familial status, or other characteristics protected by law. Equal employment is extended to all person in all aspects of the associate-employer relationship including recruitment, hiring, training, promotion, transfer, compensation, discipline, reduction in staff, termination, assignment of benefits, and any other term or condition of employment