HIM Coding - Clinical Documentation Educator

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Department: Health Information Management
Shift/schedule: Full Time (40 hrs/wk)

GENERAL SUMMARY

Works under the supervision of the Health Information Manager. The primary job function of the Health Information Management Coding and Clinical Documentation Educator is to oversee the HIM coding compliance program, to include coding, auditing and query Processes. This position is responsible for DRG validation accuracy, auditing of inpatient and outpatient surgery records, and provide on-going feedback and continuing education to coders and clinicians. Maintains statistics on Query, DRG, surgical documentation and coding accuracy rates for the organization and continually monitors progress, as well as being available as a resource. Provides inpatient coding coverage as needed. Performs other duties as assigned.

QUALIFICATIONS

Education:

• High School Diploma or successful completion of an equivalent High School Exam required
• Associates Degree in Health Information or equivalent inpatient coding and/or clinical documentation experience required

Licensure:

• Certified Coding Specialist (CCS) or Registered Health Information Technician (RHIT) required
• Certified Clinical Documentation Specialist (CCDS) preferred

Experience:

• Five years of recent acute care hospital coding and/or clinical documentation improvement experience preferred

JOB SPECIFIC DUTIES AND PERFORMANCE EXPECTATIONS

The following is a summary of the major job duties of this job. Other duties may be performed, both major and minor, which are not mentioned below. Specific activities may change from time to time.

1. Complies with all policies and procedures.
2. Audits complex coded records for inpatient and outpatient hospital records consistently and accurately.
3. Creates clear and concise audit reports of findings post coding and CDI quality checks.
4. Implements and maintains a formalized review process that incorporates regular audits of staff, target DRG’s and Queries. Provides necessary feedback and education resulting from audit results.
5. Identifies trend analyses to identify patterns, variations in coding practices and case mix.
6. Coordinates ongoing education and training to new and existing coders and clinical documentation staff.
7. Acts as a resource on coding issues and questions to ensure accurate coding for appropriate reimbursement and data capture.
8. Provides coding coverage as needed.
9. Demonstrates knowledge of current healthcare regulatory billing and coding issues, coding mandates, and reimbursement rules and guidelines.
10. Assists in query resolution by working one on one with providers on query completion.
11. Performs other duties as assigned.

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Southern Ohio Medical Center is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, disability, ethnicity, gender identity, or expression, genetic information, military status, national origin, race, religion, sex, gender, sexual orientation, pregnancy, protected veteran status or any other basis under the law.