Employment Type: Full Time
Shift: Day Shift

Description:
Join our team as a vital contributor in the analysis and assessment of physician and provider documentation within Inpatient health records. We are seeking an individual with exceptional technical aptitude and subject matter expertise to accurately determine principal and secondary diagnoses, procedures, and effectively assign Medicare Severity Diagnosis Related Groups (MS-DRG), All Patient Refined DRGs (APR), as well as pertinent Present on Admission (POA), Severity of Illness (SOI), and Risk of Mortality (ROM) indicators. Your expertise will play a key role in identifying Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI), ensuring accurate reimbursement for our facility. In this role, you will leverage encoder software applications, utilizing all relevant online tools and resources to assign International Classification of Diseases, Clinical Modification (ICD-CM) diagnosis and procedure codes.

Essential Functions:
1. Uphold and embody the Trinity Health Mission, Vision, and Values in every action and decision.
2. Skillfully navigate patient health records and various computer systems to ensure precise diagnosis and procedure coding, while identifying HACs and PSIs that influence quality data and hospital reimbursement.
3. Utilize encoder software to code Inpatient health records, consistently referring to online tools to support the coding process, and accurately assign ICD codes, MS-DRG, APR DRGs, POA, SOI, and ROM indicators.
4. Review Inpatient documentation meticulously to gather clinical evidence supporting diagnosis codes, effectively minimizing denial risks.
5. Address Inpatient claim edits and code consecutive/combined accounts in compliance with the 72-hour rule and relevant guidelines.
6. Adhere to established Inpatient coding quality and productivity standards as set by Revenue Excellence/HM.
7. Engage with physicians, Clinical Documentation Specialists (CDS), and other healthcare providers to apply compliant coder query practices whenever additional detail is necessary or documentation is ambiguous.
8. Implement EMR communication tools to monitor missing documentation or Inpatient queries, ensuring prompt coding.
9. Collaborate with HIM and Patient Business Services (PBS) teams to resolve any billing, claims, denial, or appeals matters affecting reimbursement.
10. Maintain Continuing Education Units (CEUs) relevant to your coding credentials as required by credentialing organizations.
11. Stay current with the latest developments in Inpatient coding and reimbursement guidelines, including emerging applications such as Hospital at Home.
12. Identify and troubleshoot coding and EMR workflow issues that could affect the coding process.
13. Demonstrate awareness of ethical concerns in health record documentation and coding, alerting leadership when necessary for resolution.
14. Complete other duties as assigned by leadership.
15. Maintain a comprehensive understanding of applicable coding and reimbursement regulations at the federal, state, and local levels while upholding the Compliance Accountability Program and Code of Ethics in all professional interactions.

Minimum Qualifications:
1. A completed AHIMA-approved coding program or an Associate’s degree in Health Information Management (HIM) or a related field is required. A Bachelor’s degree in HIM or a related healthcare discipline is preferred.
2. Required credentials include Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS).
3. A minimum of three years of recent acute care or Inpatient coding experience is necessary, along with a thorough understanding of medical terminology, Anatomy and Physiology, as well as diagnostic and procedural coding, including MS-DRG and APR DRG assignments. Proficiency in identifying POA, SOI, ROM indicators, HACs, and PSIs is crucial for ensuring accurate hospital reimbursement.
4. Experience with encoding/grouping software and Computer Assisted Coding (CAC) is a plus.
5. Proficient use of standard desktop/laptop computers, email, Windows applications, the internet, and web-based training tools is preferred.
6. Strong verbal and written communication skills are essential, including the ability to effectively engage with diverse groups.
7. Capability to research, analyze, and synthesize information from various sources is vital.

Hourly Pay Range: $27.41 – $41.13

Our Commitment to Diversity and Inclusion
Trinity Health proudly stands as one of the largest non-profit, Catholic healthcare systems in the United States. Rooted in our Mission and Core Values, we prioritize diversity, equity, and inclusion in every aspect of our operations. Our colleagues bring a rich array of experiences, traditions, abilities, and talents, coming together to enhance the care we provide. A diverse and inclusive workforce is instrumental in delivering accessible and equitable healthcare to all we serve. Trinity Health is proud to be an Equal Opportunity Employer; all qualified candidates will be considered for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability status, veteran status, or any other status protected by law.