Job description

The Inpatient Coding and Documentation Specialistis a professional who has values and beliefs that are consistent with those of Santiam Hospital.

Examples Of Essential Duties:

Functions Specific to Role as Inpatient Coding and Documentation SpecialistReview health information record documentation about hospital inpatients (“documentation”), and collaborate with Hospital staff and Medical Staff to ensure documentation accuracy, completion, and specificity that are sufficient to facilitate optimal medical coding.
Documentation Quality Compliance

• Within seventy-two hours after inpatient admission, review documentation about patient course, identify deficiencies in documentation necessary for appropriate medical code assignment and designations of patient condition severity and patient care acuity, notify applicable Medical Staff that such deficiencies are present, and direct notified Staff to correct such deficiencies.
• As is needed, follow up with Medical Staff about requests that relate to need for documentation clarification or improvement, and, when indicated, engage Chief Medical Officer or Inpatient Care Clinical Service Medical Director to assist with resolution of unheeded requests.
• Collaborate with other Health Information Management Service staff members to ensure that accurate and comprehensive coding for inpatient services is consistently completed.Staff Member Education
• Use known improvement practices, formulate and implement novel strategies, and employ proven methods that are specific to Hospital culture to educate Hospital staff and Medical Staff about documentation best practices, improve documentation quality, and facilitate documentation compliance with applicable billing and regulatory requirements.
• Educate Medical Staff about pertinent coding designations, guidelines, and terminology, with intent to facilitate provider understanding about elements that are crucially needed for documentation optimization, importance of disease reporting accuracy, significance of patient diagnosis code (i.e. “ICD-10 Code”) capture, and particular reimbursement topics that may include evaluation and management codes, healthcare pay for performance, and provider profiling based on performance or patient care provision.
• Provide to Medical Staff specific direction about documentation that will support accurate ICD-10 Code capture of designations for patient acuity, condition severity, diagnosis-related group assignment, and mortality risk.Payer Relations
• Liaison with healthcare payers with intent to facilitate inpatient claim authorization, minimize denial of claims or claim portions (i.e. “carve-outs”), and, when requested, participate in related discussion or review.
• Perform indicated initial and secondary review that relates to inpatient level of care, medical necessity, or continued hospitalization.
• Assist, as is applicable, with denial management process.Performance Improvement
• Develop, implement, and surveill means to analyze revenue capture ability, assess compliance with applicable billing and regulatory standards, and evaluate documentation integrity; and report to Revenue Cycle Director and Health Information Management Manager about findings and trends suggested during such analysis, assessment, and evaluation.
• Contribute to Hospital efforts directed toward applicable cost containment, appropriate resource utilization, and reduction of inappropriate hospital admissions.
• As is indicated, participate in healthcare multidisciplinary team rounds.
• Regularly attend Utilization Review Committee meetings.Coordinate Revenue Cycle Department service provision with that of all other Hospital Departments in general and, in particular, through appropriate liaison with Medical Staff and Integrated Health and Outreach Department staff members who specialize in care management, discharge planning, resource management, social services, and utilization management to optimize both provision of such services and inpatient care quality.

Perform other duties assigned by Health Information Management Manager or Revenue Cycle Director.

Typical Qualifications:

• knowledge of principles that relate to the position, including general knowledge about human disease processes, disease treatments, treatment indications, and requirements, imposed by healthcare payers, for applicable provider documentation about patient diagnosis, illness severity, mortality risk, and treatment justification
• aptitude in verbal and written communication, including ability to communicate with persons in all age groups
• possession of one of the following certification or education backgrounds:
• certification as a Registered Health Information Administrator or a Registered Health Information Technologist
• a four-year degree from an accredited nursing school
• possession, within 12 months after hire, of at least one of the following certifications:
• Certified Clinical Documentation Specialist
• Certified Coding Specialist
• Certified Documentation Improvement Practitioner
• possession of other applicable certification, registration, and Oregon licensure
• possession of at least three years of experience in a healthcare setting, including at least two years in a position that involved assessment of healthcare documentation integrity
• possession of United States proof of citizenship or right to work in the United States
• possession of a driver license or analogous identification
• willingness to participate in Hospital orientation and educational in-service

Supplemental Information:

401(k) Retirement plan
Health, dental and vision insurance for staff and family
PTO, holidays and extended medical leave bank
Hospital Incentive Plan (HIP)
Life insurance
Long-term disability Insurance
Staff discounts

Santiam Hospital & Clinics is an EEO Affirmative Action Race/Sex/Sexual Orientation/Gender Identity/National Origin/Veteran/Disability Employer.

Job Type: Full-time

Pay: From $28.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Employee discount
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Stayton, OR 97383: Reliably commute or planning to relocate before starting work (Required)

Experience:

• ICD-10: 1 year (Preferred)

Work Location: One location

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