The role of the Coder Outpatient Level III is to interact extensively with the physician and others members of the health care team to facilitate the improvement in the overall quality, completeness and accuracy of medical record documentation. This will support the appropriate clinical picture and level of severity of the patient while providing accurate and complete information that is utilized in the medical record and core measure abstraction and coding process to obtain appropriate reimbursement. This position will also be responsible for coordinating and providing education to all physicians and other clinicians related to compliant documentation responsibilities and coding and abstraction issues. This position will identify opportunities for documentation improvement to ensure accuracy and completeness of documentation used for measuring and reporting physician and hospital outcomes (e.g. patient safety indicators (PSI) and hospital acquired conditions (HAC). The Coder Outpatient Level III will collaborate as necessary with other disciplines as necessary to communicate these opportunities for referral to the appropriate performance improvement committee for resolution. This position will primarily review outpatient hospital based medical records using nationally recognized guidelines assure accurate and complete documentation of diagnoses and CPT procedures and HCPCS code assignment. The Coder Outpatient Level III will demonstrate understanding of complications, co-morbidities, severity of illness, risk of mortality, secondary diagnosis, risk-adjustment methodologies and impact of procedures on the final code assignment. The Coder Outpatient Level III will demonstrate understanding of various system edits and the impact on reimbursement.

QUALIFICATIONS

EDUCATION: High School diploma required. Associate of Science Degree in Health Information Technology preferred. Bachelors of Science HIM preferred. RHIA or RHIT preferred.

LICENSE/CERTIFICATION: CPC or (COC previously CPC-H) required. Successful completion of a college based coding program or college based coding certificate program preferred (AHIMA-approved preferred).

EXPERIENCE:  Minimum 5 years outpatient hospital based coding (recent hands on production) experience required.  Proficiency in Clinical and Business Applications preferred at

time of hire; incumbents within position will be trained appropriately and then skill will be required for this position within 30-60 days from date of hire.

PERFORMANCE EXPECTATIONS

Demonstrates the technical competencies as established on the Assessment and Evaluation Tool.

WORK ENVIRONMENT

This active position requires the ability to work in a busy patient care area. Near visual acuity, long periods of visually examining documents and electronic files, and skilled use of multiple computer applications required.  The Health Data Integrity Specialist works independently and autonomously with minimal supervision. Critical thinking and strong customer services skills required and manage daily work duties accurately and efficiently

The essential functions for this position are listed on the Assessment and Evaluation Tool.

REPORTING RELATIONSHIP

This position reports to department leadership.

The above statement reflect the general details considered necessary to describe the principle functions of the job as identified and shall not be considered as a detailed description of all work requirements that may be inherent in the position.