Coder 4 Inpatient
Company: Dignity Health
Posted on: June 3, 2021
Mercy Medical Center, a Dignity Health member, has been building
a rich history of care in our community for more than 100 years. We
have grown from a small one-story wooden structure into a major
healthcare provider with a new 186-bed main campus, offering the
latest in facility design and technology. Mercy also operates
Outpatient Centers, a Cancer Center and several rural clinics.
Wherever you work throughout our system, you will find faces of
experience with dedication to high quality, personalized care.
Joining our 1,300 employees, 230 physicians and many volunteers,
you can help carry out our commitment to providing our community
with the excellence they have come to associate with Mercy Medical
The Coder IV is a member of the Health Information Management
Team responsible for ensuring the accuracy and completeness of
clinical coding, validating the information in the databases for
outcome management and specialty registries, across the entire
integrated healthcare system. The purpose of this position is to
apply the appropriate diagnostic and procedural codes to individual
patient health information records for data retrieval, analysis and
claims processing. This position is expected to perform duties in
alignment with the mission and policies within the Dignity Health
organization, TJC, CMS, and other regulatory agencies.
Principle Duties and Accountabilities:
- Assign codes for diagnoses, treatments, and procedures
according to the appropriate classification system for inpatient
- Can also code ancillary, emergency department, same-day
surgery, and observation charts if needed.
- Review provider documentation to determine the principal
diagnosis, co-morbidities and complications, secondary conditions
and surgical procedures following official coding guidelines.
- Utilize technical coding principals and APC reimbursement
expertise to assign appropriate ICD-IO-CM diagnoses, ICD-IO-PCS as
appropriate, and CPT-4 for procedures.
- Understanding of ICD10 Coding in relation to DRGs
- Abstract additional data elements during the chart review
process when coding, as needed
- Utilize technical coding principals and MS-DRG reimbursement
expertise to assign appropriate ICD-10- CM diagnoses and ICD-
- Ensure accurate coding by clarifying diagnosis _and procedural
information through an established query process if necessary.
- Assign Present on Admission (POA) value for inpatient
- Extract required information from source documentation and
enter into encoder and abstracting system.
- Identifies non-payment conditions; Hospital-Acquired Conditions
(HAC), Patient Safety Indicators (PSI) following, report through
- Collaborate in the DRG Mismatch process with the Clinical
Documentation Improvement team.
- Review documentation to verify and when necessary, correct the
patient disposition upon discharge.
- Prioritize work to ensure the timeframe of medical record
coding meets regulatory requirements.
- Serve as a resource for coding related questions as
- Adhere to and maintain required levels of performance in both
Coding accuracy and productivity.
- Review and maintain a record of charts coded, held, and/or
- Provide documentation feedback to Providers, as needed
- Participate in Coding department meetings and educational
- Meet performance and quality standards at the Coder III
- Abide by the Standards of Ethical Coding as set forth by the
American Health Information Management Association (AHIMA) and
adheres to official coding guidelines.
- Other duties as assigned that have a direct impact on our
ability to decrease the DNFB and support Revenue Cycle, including
but not limited to charge validation, observation calculations,
- 3 years of relevant coding and abstracting experience or
equivalent combination of education and experience required in an
acute care hospital setting
- Completion of an AHIMA or APPC accredited coding certification
program that includes courses that are critical to coding success
such as: Anatomy and physiology, pathophysiology, pharmacology,
Anatomy / Physiology, Medical Terminology and ICD-10 and CPT coding
- High School Diploma or equivalent required
- Have and maintain current coding credential from AHIMA or AAPC
(RHIA, RHIT, CCS, CCS-P, CPC, or CPC-H )
- A minimum of 3 years Inpatient medical coding experience
(hospital, facility, etc.)*
- Must have ICD-10 coding experience
- Must have experience with DRG coding
- Ability to use a PC in a Windows environment, including MS Word
and EMR systems
- Ability to pass all pre-employment requirements including, but
not limited to: drug screening, background check, and coding
- One year of experience will be waived for those who have
attended the Dignity Health Coding Apprenticeship Program.*
- Experience with various Encoder systems (i.e., OptumCAC,
- Experience working in a 200 or greater bedside acute care
hospital or hospital system
- Intermediate level of Microsoft Excel
- 5+ years inpatient medical coding experience (hospital,
Knowledge, Skills and Abilities:
- Analytical / Critical thinking and problem solving
- Knowledge and application of ICD-10-CM, ICD-10-PCS, HCPCS and
CPT-4 classification systems
- Excellent written and verbal communication skills, including
the ability to present ideas and concepts effectively across
- Knowledge of information privacy laws, access, release of
information, and release control technologies
- Knowledge of hospital protocols and procedures
- Working knowledge of functional relationships between
departments within a healthcare or similar environment
- Knowledge of TJC, HIPAA, HCFA, Title 22, security principles,
guidelines, and standard healthcare practices
- Demonstrated competence with personal computers, networks, and
This position is an on-site position, remote work option is not
Keywords: Dignity Health, Merced , Coder 4 Inpatient, Other , Merced, California
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