Medical Records Coder and Abstractor II

Job Overview:

Reviews and interprets clinical documentation to assign accurate and complete codes, modifiers, MSDRG's, APR-DRG's, SOI, ROM, POA indicators, discharge dispositions and any other clinical data elements required for appropriate reimbursement. Understands and applies reimbursement processes under federal compliance guidelines. Abstracts demographic and clinical data into hospital health information system(s) such as HDM, Epic, or other currently in use. Performs and responds to data quality checks and payer/claims issues. One may specialize in one or more of the standard functions. Specific assignments will vary from day to day based on the needs of the department.

Must reside in Ohio, Indiana, Kentucky, or Michigan.  Will be required to come onsite once a quarter for any required department or TriHealth education.

Job Requirements:

Currently enrolled in an approved program for specific field of study. (Required)
Proficiency in ICD and CPT coding 
DRG’s 
MSDRG’s 
POA indicators 
Post-acute transfer rules 
Disposition status 
Disease process and treatment 
Anatomy and medical terminology 
Clinical documentation requirements 
AHIMA
RHIT - Registered Health Information Technician RHIT - Registered Health Information Technician Continuing education pursued in accord with requirements of the accrediting bodies. within 180 Days Required 
RHIA - Registered Health Information Administrator RHIA - Registered Health Information Administrator Continuing education pursued in accord with requirements of the accrediting bodies. within 180 Days Required or 
CCS - Certified Coding Specialist CCS-Certified Coding Specialist Continuing education pursued in accord with requirements of the accrediting bodies. within 180 Days Required or 
Other Certified Professional Coder (CPC) may be substituted at the hiring manager’s discretion. within 180 Days Required or 
CCA – Certified Coding Assoc CCA - Certified Coding Associate may be substituted at the hiring manager’s discretion. within 180 Days Required or

Job Responsibilities:

Independently and confidently delivers high quality results utilizing coding resources and provided education. Reviews and interprets clinical documentation to assign accurate and complete codes, modifiers, DRG’s, and POA indicators. 
Consistently meets monthly productivity goals set by department. Productivity guidelines for activities involved in the coding process are as follows: 1.25 Med/Surg cases per hour, 2 observations per hour, 2.5-3 OB/NB cases per hour, 3 Outpatient Surgeries per hour, 12 ED's per hour, 34 Ancillaries 5=>150, 4=149-120, 3=119-100, 2=99-80, 1=<80 
Abstracts demographic and clinical data into hospital health data management systems. Discharges dispositions and other required data elements. 
Engaged team member. Highly regarded for their work and leadership. Problem solves and develops solutions when raising issues. Positive role model and has influence on peers. Displays confidence and initiative. Volunteers to be a part of educational training sessions, volunteers for minutes and reflections for meetings. Goes out of the way to be an interactive part of the coding team. Attends all team meetings, takes advantage of extra educational opportunities, student mentoring education, team member ambassador program, etc. as needed/requested. Completes all bright ideas and required trainings on time.

Working Conditions:

Bending - Rarely 
Climbing - Rarely 
Concentrating - Consistently 
Continuous Learning - Consistently 
Hearing: Conversation - Frequently 
Hearing: Other Sounds - Frequently 
Interpersonal Communication - Consistently 
Kneeling - Rarely 
Lifting <10 Lbs. - Rarely 
Lifting 50+ Lbs. - Rarely 
Lifting <50 Lbs. - Occasionally 
Pulling - Occasionally 
Pushing - Occasionally 
Reaching - Occasionally 
Reading - Consistently 
Sitting - Occasionally 
Standing - Frequently 
Stooping - Occasionally 
Talking - Frequently 
Thinking/Reasoning - Consistently 
Use of Hands - Frequently 
Color Vision - Frequently 
Visual Acuity: Far - Frequently 
Visual Acuity: Near - Consistently 
Walking - Frequently

TriHealth SERVE Standards and ALWAYS Behaviors

At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members. To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:

Serve: ALWAYS... 
• Welcome everyone by making eye contact, greeting with a smile, and saying "hello" 
• Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist 
• Refrain from using cell phones for personal reasons in public spaces or patient care areas

Excel: ALWAYS... 
• Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met 
• Offer patients and guests priority when waiting (lines, elevators) 
• Work on improving quality, safety, and service

Respect: ALWAYS... 
• Respect cultural and spiritual differences and honor individual preferences. 
• Respect everyone's opinion and contribution, regardless of title/role. 
• Speak positively about my team members and other departments in front of patients and guests.

Value: ALWAYS... 
• Value the time of others by striving to be on time, prepared and actively participating. 
• Pick up trash, ensuring the physical environment is clean and safe. 
• Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

Engage: ALWAYS... 
• Acknowledge wins and frequently thank team members and others for contributions. 
• Show courtesy and compassion with customers, team members and the community