Oswego Health

Job Title: Coder I Department: Health Information Management

Reports to: Coding Manager Revision Date: 08/17/2020

Status: Non-Exempt

Job Summary:

The Health Information Management Coder I performs medical record review and analysis in order to translate clinical information into coded data. These diagnosis and procedure codes are utilized for billing, internal and external reporting, research, and regulatory compliance.

Duties/Responsibilities:

• Document ICD-10-CM diagnosis and procedure codes and CPT-4 procedure codes, ensuring all necessary and appropriate documentation is present and complete.
• Assign codes following coding principals for proper reimbursement.
• Code outpatient (for example, diagnostic, therapeutic, emergency department services, ambulatory surgery (same day surgery) and observation services) conditions.
• Assign indicator codes, discharge disposition, and other data elements as found in the medical record.
• Resolve error reports associates with billing process, assist in design and implementation of workflow changes to reduce errors.
• Analyze medical record documents (including history and physical, operative notes, pathology, laboratory and radiology reports, consultations, nurse notes, doctors’ orders, discharge summary and progress notes) in order to determine final diagnoses and significant procedures.
• Apply appropriate reference materials and on-line coding resources while assigning codes.
• Understand outpatient coding principals for correct code assignment for proper reimbursement.
• Maintain a 95% level of accuracy in the coding of data/information (code selection and sequencing).
• Maintain a 90% level of productivity per coding productivity standards.
• Document modifier codes as needed on CPT-4 procedures as well as date and performing physician on all procedure codes.
• Refer deficient/delinquent records to the appropriate member of the department staff.
• Note all diagnosis, operation, and procedure discrepancies, referencing physician as needed.
• Perform other duties as assigned.

Required Skills/Abilities (Unit Specific):

• Knowledge and training in ICD-10-CM/PCS and CPT required.
• Knowledge of human anatomy and physiology and medical terminology required.
• Maintain reference material on a continuing basis as relates to training, education, and routine procedures.
• Exercises expert skill and independence in coding of prescribed record types under the supervision of the Coding Manager.

Education and Experience:

• Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coder Apprentice (CCA) in an active status with American Health Information Management Association required.
• CCA, CCS, RHIT, or RHIA required (must already possess a coding certification).
• American Academy of Professional Coders or AHIMA.
• Minimum of two years work experience as a coder in acute care or physician office setting using ICD-10-CM/PCS or CPT coding required.
• Completion of a coding certificate through an AHIMA affiliated organization preferred.

Working Conditions:

• Extended periods of sitting at a desk working with computers.
• Operation of software and equipment including Meditech Expanse, RD Web, 3M Coding and Abstracting, fax machine, copier, and/or component software.
• Requires ability to lift, move, carry, push or pull up to 25lbs. using proper body mechanics.
• Actively participates in Clinical Quality Improvement programs.
• Actively participate in cross-training, in-service programs; attend all mandatory classes, meetings and committees as required; complete department-specific requirements/competencies.
• Attendance ensures that job requirements are met.
• Complies with DOH requirements for annual health assessments and required immunizations.

Pay Range: $23.25-$25.75/hr

Employee salary is based on commensurate experience and other qualifications.

The mission of Oswego Health is to provide accessible, quality care and improve the health of residents throughout Oswego County. As a nonprofit healthcare system that was established in 1881, Oswego Health is proud to continue to be one of Oswego County’s largest employers. More than 1,200 employees spread throughout its 17 locations, work for the Oswego Health system, which includes the 164-bed community hospital with a brand new Medical Surgical Unit, a 32-bed state-of-the-art psychiatric acute-care facility with multiple outpatient behavioral health service locations, The Manor at Seneca Hill, a 120-bed skilled nursing facility, and Springside at Seneca Hill, an independent retirement community. The health system also operates Oswego Health Home Care, the only hospital-based certified home healthcare agency in the County as well as two outpatient centers, including the Fulton Medical Center, offering urgent care, lab, medical imaging, physical therapy, and occupational health services; and the Central Square Medical Center, offering urgent care, lab, medical imaging, and physical therapy services. In addition, Oswego Health includes the Oswego Health captive professional corporation, Physician Care P.C., providing physician services in orthopedics, cardiology, ENT, gastroenterology, breast care, audiology, general surgery, bariatrics, and primary care.

EQUAL EMPLOYMENT OPPORTUNITY

Oswego Health is committed to providing equal opportunity in all employment-related matters, without regard to race (including traits historically associated with race), creed, color, religion, sex/gender, national origin, age, marital or familial status, disability, pregnancy-related condition, sexual orientation, gender identity, gender expression, transgender status, citizenship status, ancestry, arrest/conviction record, military or veteran status, domestic violence victim status, genetic predisposition or carrier status, reproductive health decision making, relationship or association with a member of a protected category, or any other legally protected characteristic. Decisions affecting your position including, but not limited to, recruitment, hiring, placement, promotion, transfer, compensation, benefits, training, tuition assistance, leaves of absence, disciplinary action, layoff/recall, and terminations will be made in accordance with this policy.