Clinical Coding Specialist

The Clinical Coding Specialist is responsible for the analysis of inpatient and outpatient medical records to identify principle, secondary, and subsequent diagnosis and/or procedures, and sequencing to optimize reimbursement.  S/he is responsible for the coding of medical charts using ICD and CPT classification systems; the abstracting of medical records into computerized database; performing audits for correct coding; and compiles reports for department and hospital committee meetings.

Qualifications:

Required Education:

• Associate’s degree in Health Information Management or related field.
• Graduate of an accredited Health Information Management or Technical program.
• RHIA, RHIT or CCS certification.
• Previous experience as an inpatient coder – preferably 2 years or more.
• Experience in an acute setting.
• Well versed on coding guidelines.

Desirable Education:

• Bachelor’s degree in Health Information Management or related field.

 Required Experience:

• Have a good working knowledge of various medical coding and reimbursement software program experience.

 Desirable Experience:

•  At least two (2) years of coding experience in a hospital setting.

Duties & Responsibilities:

• Ensure that records are coded within 72 hours of discharge.
• Thoroughly review charts to ascertain all diagnoses and procedures.
• If diagnoses are not available in the chart, contact responsible physician in a professional, tactful manner.
• Utilize computerized coding/abstracting software.
• Code all diagnoses and procedures in accordance to ICD and CPT coding principles and Coding Manual.
• Meet productivity standards of assigning codes to a minimum of 3.0 inpatient charts per hour.
• Meet quality standards of having 98% of principle diagnoses and procedures approximated and correctly coded.
• Maintain 99% rate of information correctly abstracted.
• Update the Coding Manual on an ongoing basis.
• Act as a resource person to hospital staff in coding and provide education on coding changes and/or issues.
• Design data collection tools and develops process/outcome studies pertaining to coding and reimbursement.
• Responsible for conducting inpatient and outpatient medical chart coding and abstracting utilizing various computerized systems.
• Conduct ongoing medical chart review and audits for correct coding and abstracting.
• Compile reports of audits for presentation of findings with the appropriate departmental or hospital committee.
• Keep informed of current professional trends or changes in standards pertaining to health information management professionals.

A Roman Catholic facility founded by the Religious Hospitallers of St. Joseph and sponsored by Catholic Health International, St. Bernard Hospital aspires to live in the healing mission of Christ within the South Side community of Chicago. This mission calls us to care for the sick and promote the health of the residents in the community while witnessing the Christian values of respect, dignity, caring and compassion for all persons. In all matters, St. Bernard Hospital will show a special sensitivity to the culture of the people we serve and the unique needs of the poor and powerless.