Employment Type: Full-Time
Shift: Day Shift

Role Overview:
We are seeking an experienced professional with exceptional technical skills and in-depth knowledge to evaluate physician and provider documentation within Inpatient health records. Your primary responsibility will be to identify principal and secondary diagnoses as well as procedures, ensuring accurate coding for reimbursement purposes. You will assign the appropriate Medicare Severity Diagnosis Related Groups (MS-DRG), All Patient Refined DRGs (APR), Present on Admission (POA), and indicators for Severity of Illness (SOI) and Risk of Mortality (ROM) for Inpatient records. Your expertise will also extend to recognizing Hospital Acquired Conditions (HAC) and Patient Safety Indicators (PSI) to guarantee precise hospital reimbursement. Proficiency in encoder software and all relevant online resources will be crucial in assigning International Classification of Diseases, Clinical Modification (ICD-CM) codes accurately.

Key Responsibilities:
– Embrace and exemplify the Mission, Vision, and Values of Trinity Health in all professional interactions and decision-making processes.
– Efficiently navigate patient health records and various computer systems to accurately derive diagnosis and procedure codes, MS-DRGs, APR DRGs, and identify relevant HACs and PSIs or other quality indicators influencing hospital reimbursement.
– Utilize encoder software to code Inpatient health records, consistently referencing online tools and applications to assign ICD codes, MS-DRGs, APR DRGs, POA, SOI, and ROM indicators.
– Conduct thorough document reviews within health records to identify clinical evidence supporting diagnosis codes and DRG assignments, proactively reducing denials.
– Manage inpatient claim edits and code combined accounts when necessary to adhere to the 72-hour rule and additional account combination scenarios.
– Maintain compliance with established coding quality and productivity standards set by Revenue Excellence/HM.
– Exhibit knowledge of current coder query practices, collaborating with physicians, Clinical Documentation Specialists (CDS), and other healthcare professionals when additional clarification on documentation is required.
– Employ EMR communication tools to monitor outstanding documentation and facilitate timely coding through follow-ups on Inpatient queries.
– Collaborate with Health Information Management (HIM) and Patient Business Services (PBS) as needed to address billing, claims, denial, and appeals challenges impacting reimbursement.
– Keep abreast of continued education units (CEUs) relevant to coding credentials as required by professional associations.
– Stay updated on changes in Inpatient coding and reimbursement guidelines, regulations, and emerging applications, such as Hospital at Home.
– Proactively identify and address coding workflow issues impacting efficiency.
– Maintain ethical coding practices, reporting documentation discrepancies or concerns to leadership for resolution.
– Perform additional duties as assigned by leadership.
– Uphold knowledge of applicable federal, state, and local laws and regulations related to coding and reimbursement, ensuring adherence to policies reflecting ethical and professional behavior.

Qualifications:
– Completion of an 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 comparable healthcare discipline is preferred.
– Required certifications include Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS).
– A minimum of three (3) years of experience in acute care or Inpatient coding, demonstrating extensive knowledge of medical terminology, anatomy and physiology, diagnostic and procedural coding, as well as MS-DRG and APR DRG assignment proficiency.
– Proficiency in identifying POA, SOI, and ROM indicators, as well as HACs and PSIs for accurate hospital reimbursement.
– Current experience with encoding/grouping software and Computer-Assisted Coding (CAC) is advantageous.
– Familiarity with standard desktop and laptop operations, Microsoft applications, and web-based training tools is preferred.
– Excellent oral and written communication skills, with an ability to engage effectively with diverse individuals and groups.
– Strong research, analytical, and problem-solving skills to assimilate information from multiple sources.

Hourly Pay Range: $27.41 – $41.13

Diversity and Inclusion Commitment:
Trinity Health, one of the nation’s largest not-for-profit Catholic healthcare systems, is grounded in our core Mission and Values. We prioritize diversity, equity, and inclusion in all our practices. Our team is composed of individuals with varying experiences, abilities, and talents, enabling us to provide the best care possible to our communities. We are proud to be an Equal Opportunity Employer, welcoming applications from all qualified candidates regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other protected status by law.