At Central Maine Healthcare our team members are committed to providing exceptional care and experiences for our community and for each other every day.

Position Summary: The Clinical Coder, HIM is accountable for conversion of diagnoses and treatment procedures into codes using international classification of diseases CPT coding classification systems. Requires skill in the sequencing of diagnoses/procedures to optimize reimbursement. Requires the ability to abstract clinical information from the inpatient record and identify clinical findings which suggest a need for clarification by the attending or consulting physician in order to accurately reflect the care and treatment of the patient. Ensures that records are coded in an accurate and timely manner. Duties and Responsibilities: Demonstrates Competency in the Following Areas: 1. Ensures that records are coded within 2 days of discharge for inpatient accounts, and 7 days for out patient accounts, if they meet the requirements of completeness as defined in the policy and procedure manual (excluding weekends and holidays). 2. Reviews chart thoroughly to ascertain all diagnoses/procedures. 3. Contacts responsible physician with query form, if diagnosis is not available on chart, or if further clarification is needed to accurately code a record or episode of care. 4. Refers chart to coding manager or director if there is a question regarding the diagnoses/codes. 5. Utilizes computerized coding/abstracting equipment. 6. Codes all diagnoses/procedures in accordance to ICD-9-CM andCPT coding principles and Coding Clinic guidelines. 7. Performs data entry for diagnoses, procedures and other abstracating data elements as outlined in departmental procedures. 8. Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded. 9. Maintains 98% rate of information correctly abstracted. 10. Maintains the number of DRG/coding changes below the 3% quarterly per PRO threshold. 11. Reviews coding periodicals within 7 days of receipt. 12. Notifies coding manager or director whenever work is more than 48 hours behind work deadline. 13. Assists the coding manager or director with state requirements and reports. 14. Ensures data quality and optimum reimbursement allowable under the federal and state payment systems. 15. Able to prioritize work independently and meet production deadlines on a daily basis. 16. Works closely with staff in Patient Financial Services to resolve registration and billing errors and facilitate timely filing of claims. 17. Acts as a resource person to hospital staff for coding and may provide education regarding coding changes/issues. 18. Assists in answering the telephones and taking accurate messages. 19. Maintains a good working relationship within the department, other departments and medical staff. 20. Must be familiar with the following manuals: Administration, Health Information Management Services, Emergency Management and Safety. 21. Willing to accept additional assignments. 22. Performs performance improvement functions through data collection and documentation review. 23. Customer Service: Interacts with all individuals in a consistent manner, providing attention, support, and assistance to foster an environment of exceptional personal service. a. Maintains a pleasant and helpful demeanor, and presents a professional appearance toward all internal and external customers at all times. b. Consistently initiates interaction to provide assistance to individuals who may not be direct customers of the employee (i.e. asks patients who appear to be lost if they need assistance in finding their way). c. Takes appropriate action to recover from a service difficulty, ensuring that the necessary action is taken to affect a resolution to the customer’s problem. d. Conducts all work activities with respect for coworkers, including the maintenance of a pleasant and professional environment, fostering calmness during stressful situations. e. Interacts with supervisory personnel in a professional, supportive and courteous manner, venting emotions appropriate to time and place. f. Demonstrates a commitment to service by consistent attendance and punctuality, scheduling absences according to departmental requirements, and incurring unplanned absences only when unavoidable circumstances exist. Organizational Requirements: 24. Adheres to dress code, appearance is neat and clean. 25. Completes annual education requirements. 26. Maintains regulatory requirements. 27. Reports to work on time and as scheduled, completes work within designated time. 28. Wears identification while on duty, uses computerized punch time system correctly. 29. Completes in-services and returns in a timely fashion. 30. Attends annual review and department in-services, as scheduled. 31. Represents the organization in a positive and professional manner. 32. Actively participates in performance improvement and continuous quality improvement (CQI) activities. 33. Complies with all organizational policies regarding ethical business practices. 34. Communicates the mission, ethics and goals of the hospital, as well as the focus statement of the department. 35. Confidentiality: Maintains confidentiality of information at all times. a. Consistently maintains confidentiality of all information gained during the course of employment, respecting the privacy of others. b. Understands and maintains the confidentiality of information communicated directly from the supervisor, including discussions of a counseling nature. c. Follows policies and procedures related to medico legal matters, including confidentiality, amendments of medical records, patient rights, medical records as legal evidence and informed consent d. Copies records according to policy, assuring the appropriateness of the individual requesting information from the record prior to copying, faxing, or phoning any portion of the record. 36. Safety: Demonstrates an understanding of fire and electrical safety, infection control, body mechanics, and related areas, as appropriate to position. a. Attends mandatory in-services on fire safety, electrical safety, infection control, and body mechanics. Successfully completes competency-based training in each area. b. Follows all employee health procedures, incident reporting, and infection control requirements at all times, as appropriate to the position. c. Uses proper body mechanics at all times as required by the physical demands of the position. d. Maintains a safe work environment and performs duties of the position in a manner consistent with ensuring the safety of self and others. e. Identifies safety needs in areas outside own work environment, recommending corrective action as appropriate. 37. Expense Control: Performs job duties in a manner that maximizes expense control. a. Uses supplies, equipment, and utilities in an expeditious manner b. Consistently recommends methods to control costs while maintaining a high degree of customer service. c. Performs job tasks efficiently and effectively resulting in no unplanned overtime. Regulatory Requirements: • RHIT (associate degree) minimum. CCS preferred. • 2 or more years of previous hospital experience as an inpatient coder. • Knowledge of diagnoses/procedures in accordance with ICD-9-CM coding principles for both acute care. Experience with acute rehab coding preferred. • Knowledge of E/M coding for physician services desirable. • Ability to work with physicians in a collaborative manner. Language Skills: • Ability to read and communicate effectively in English. • Additional languages preferred. Skills: • Basic computer knowledge. Physical Demands: • For physical demands of position, including vision, hearing, repetitive motion and environment, see following description. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.

If you are passionate about making a difference and are looking for your next great career opportunity, we look forward to reviewing your application!