Nuvance Health is a family of award-winning nonprofit hospitals and healthcare professionals in the Hudson Valley and western Connecticut. Nuvance Health combines highly skilled physicians, state-of-the-art facilities and technology, and compassionate caregivers dedicated to providing quality care across a variety of clinical areas, including Cardiovascular, Neurosciences, Oncology, Orthopedics, and Primary Care.
Nuvance Health has a network of convenient hospital and outpatient locations — Danbury Hospital, New Milford Hospital, Norwalk Hospital and Sharon Hospital in Connecticut, and Northern Dutchess Hospital, Putnam Hospital Center and Vassar Brothers Medical Center in New York — plus multiple primary and specialty care physician practices locations, including The Heart Center, a leading provider of cardiology care, and two urgent care offices. Non-acute care is offered through various affiliates, including the Thompson House for rehabilitation and skilled nursing services, and the Home Care organizations. For more information about Nuvance Health, visit www.nuvancehealth.org.
TITLE: INPATIENT CODER ADVANCED
DEPARTMENT: HEALTH INFORMATION MANAGEMENT
REPORTS TO: CODING MANAGER
SUMMARY: Reviews, codes and abstracts all inpatient medical records for statistical purposes and hospital reimbursement, using established coding guidelines.
Reviews primary and secondary documentation throughout medical record to delineate following:
then assigns appropriate ICD-9-CM/CPT- 4 codes to same on all inpatient cases.
Initiates a physician query when there is conflicting, incomplete, or ambiguous documentation in the record or additional information is needed for accurate coding.
Engages 3M Encoder and Clinical Documentation Management Program (CDMP) worksheets to ensure accurate and complete coding and DRG assignment.
Abstracts all require information accurately into the computer system(s) for reimbursement and statistical purposes.
Collaborates with CDMP Specialists to assign correct DRG and codes, if necessary.
Prints coding summary and places in front of patient medical record.
Maintains established performance and quality standards.
Applies applicable guidelines to all cases coded to ensure accuracy of selected codes
Accesses and research applicable reference materials to further support decision-making in code selection.
Attends required educational sessions.
Completes required continuing education credits (CEUs) to maintain certification.
Updates coding books in a timely manner.
Reads coding journals and other publications re: coding techniques.
Participates in reconciliations of CDMP DRG assignments.
Assists in addressing DRG inquiries.
Reports on software and hardware problems.
Assists in training of new coding staff.
Assists in review of cases flagged by SMART (Coding Compliance software) tool.
Assists in responding to codes rejected by Patient Accounts computer system.
Field inquiries about codes and DRG assignments, as needed.
members, visitors and medical center personnel as defined in the philosophy of Vassar
Brothers Medical Center
Displays a caring and courteous attitude and represents the medical center in a positive manner to all persons noted above.
Promotes and contributes positively to intra-departmental and inter-departmental relationships with no more than two complaints in a six-month period.
Maintains the confidentiality of employees and departmental information with no infractions.
Adheres to departmental and medical center dress codes as observed by supervisor, and wears a VBMC picture identification badge, 100% of the time.
Demonstrates willingness to assist co-workers and/or to accept additional assignments as requested to support the department's efficiency as observed by the supervisor.
Responds to all supervisor's requests for information and assists in a timely and courteous manner.
Demonstrates a high level of mental and emotional tolerance and even temperament when dealing with people; uses tact, sensitivity and sound judgment at all times.
Education: High School diploma, courses in Anatomy & Physiology, Medical Terminology, Disease Pathology, ICD-9/10-CM, CPT-4
Experience: Must have 8+ years acute care coding experience. Working knowledge of encoders and must be computer literate
License: CCS required
PHYSICAL AND MENTAL FACTORS
Physical: Occasionally requires light physical effort as in periods of standing at files or worktables, repeated changes of position within the work routine or prolonged sitting.
ENVIRONMENTAL AND WORKING CONDITIONS
Physical surroundings are pleasant and comfortable with no exposure to injury or other health hazards.