Lead Inpatient Coder

At Houston Methodist, the Lead Inpatient Coder position is responsible for providing administrative support to the department while ensuring diagnostic and procedure codes are assigned accurately to inpatient encounters based upon documentation within the electronic medical record and maintaining compliance with established rules and regulatory guidelines. This position serves as the liaison between management, staff and physicians for routine matters, resolving questions and issues. Duties may be varied and may include many of the following: organize work schedules, create work assignments, review timecards for accuracy, conduct quality assurance audits of staff performance, develop and implement quality improvement activities, train and mentor staff, provide feedback on staff performance and developmental needs, collect/analyze/report on data, prepare reports on performance and metrics, and other responsibilities of a similar nature and level.

FLSA STATUS
Non-exempt

QUALIFICATIONS

EDUCATION

• Associate’s degree or higher in a Commission on Accreditation for Health Informatics and Information Management accredited program required or additional two years of experience (in addition to the minimum experience requirements listed below) required in lieu of degree

EXPERIENCE

• Five years of relevant inpatient coding experience

LICENSES AND CERTIFICATIONS
Required

• Must have one of the following: • RHIT - Certified Health Information Technician (AHIMA) • RHIA - Registered Health Information Administrator (AHIMA) • CCS - Certified Coding Specialist (AHIMA)

SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Knowledge of coding classification systems, DRG and APC systems, official coding guidelines and coding compliance
• Knowledge of an electronic medical record and imaging systems
• Working knowledge of medical terminology, anatomy and physiology
• Proficiency with electronic encoder application
• Extensive PC knowledge - must be able to work effectively in common office software, coding software and abstracting systems
• Strong interpersonal, teamwork, training, mentoring, and leadership skills
• Ability to adapt to multiple ongoing priorities with minimal supervision, including organizing workflow and actively participating in problem-solving

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

• Promotes a positive work environment and leads the team to be dynamic and a focused work unit that actively helps one another to achieve optimal department results. Interacts and communicates effectively with members of the coding team and the appropriate stakeholders. Participates and provides good feedback during coding section meetings and coding education inservices as well as takes initiative to assist others and shares knowledge with the appropriate stakeholders on official coding guidelines.
• Serves as preceptor, mentor, and resource to less experienced staff. Orients, guides, and mentors team members to help build confidence and competency in skills, knowledge, and abilities for various department tasks. Role models to team members effective communication skills, assisting in their development of such skills. Coordinates staff schedules, as appropriate, to provide daily staff coverage to promote/maintain smooth department operations.
• Role models healthy work relationships such as mitigation of conflict, leading problem-solving and resolution efforts. Recommends initiatives to improve department scores for employee engagement.

SERVICE ESSENTIAL FUNCTIONS

• Responds promptly to internal and external customer requests. Responds promptly and appropriately to requests to code or review coded accounts for accuracy. Serves as liaison between team members, management and physicians resolving routine matters, informing or escalating to management as needed.
• Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Assigns diagnostic and procedural codes to encounters of high complexity. Maintains and achieves departmental standards of coding quality by assigning accurate ICD-9-CM/ICD-10-CM/ICD-10-PCS codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines.
• Maintains and achieves department standards of abstracting quality by reviewing accurate discharge disposition entered by nursing and corrects if necessary in order to achieve the highest quality of entered data. Assigns and enters physician identification number and procedure date correctly in the medical record abstracting system.
• Reviews medical record documentation and abstracts data into the encoder and Electronic Health Record (EHR) to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions and procedures. Utilizes all tools/resources for accuracy.
• Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official guidelines.
• Conducts quality audits on processes, outcomes, and team member performance. Documents, develops, and evaluates processes and procedures. Identifies opportunities for corrective action and process improvement, collecting data and performing analyses. Follows up on action items to ensure completion of assignments, ensuring all deadlines are met. Assists with implementation and education of department-based initiatives, standards of practice and protocols. Contributes towards improving department quality scores.

FINANCE ESSENTIAL FUNCTIONS

• Utilizes time effectively. Consistently codes and abstracts at or above departmental standards of productivity while ensuring accuracy of coding.
• Supports meeting organizational goal for Accounts Receivables (AR) associated with uncoded accounts by maintaining coding timeframes within established departmental standards and ensuring all work items assigned to the coding queues are processed in a timely manner.
• Monitors staffing and recommends adjustment in staff work assignments and schedules to support fluctuations in work volumes and ensure efficient labor cost utilization; minimizes team incidental overtime. Reviews team member’s timecards for accuracy and management approval as directed. Utilizes own time efficiently and helps other team members.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Critically evaluates her or his own performance, accepts constructive criticism, and looks for ways to improve.
• Identifies innovative solutions for quality improvement and process improvement to make processes work better for the department. Fosters a positive and constructive teaching environment by engaging co-workers in learning opportunities that are valuable and in alignment with business objectives.

SUPPLEMENTAL REQUIREMENTS
WORK ATTIRE

• Uniform: No
• Scrubs: No
• Business professional: Yes
• Other (department approved): No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area Yes
• May require travel outside Houston Metropolitan area Yes

QUALIFICATIONS

EDUCATION

• Associate’s degree or higher in a Commission on Accreditation for Health Informatics and Information Management accredited program required or additional two years of experience (in addition to the minimum experience requirements listed below) required in lieu of degree

EXPERIENCE

• Five years of relevant inpatient coding experience

LICENSES AND CERTIFICATIONS
Required

• Must have one of the following: • RHIT - Certified Health Information Technician (AHIMA) • RHIA - Registered Health Information Administrator (AHIMA) • CCS - Certified Coding Specialist (AHIMA)