Full time
Day Shift
Provides high level technical competency and subject matter expertise analyzing physician/provider documentation contained in assigned to Inpatient health records to determine the principal diagnosis, secondary diagnoses, principal procedure and secondary procedures. Provides appropriate Medical Severity Diagnostic Related Groups (MS-DRG), Present on Admission (POA), Severity of Illness (SOI) & Risk of Mortality (ROM) assignments for Inpatient records.
Utilizes encoder software applications, which includes all applicable online tools and references in the assignment of International Classification of Diseases, Clinical Modification diagnosis and procedure codes, MS-DRG, POA, SOI & ROM assignments.
Utilizes coding guidelines established by the Centers for Medicare/Medicaid Services (CMS), American Hospital Association (AHA) Coding Clinic, American Health Information Management Association (AHIMA) Standards of Ethical Coding, Revenue Excellence/Regional Health Ministry (RHM) coding policies.
Proficiently navigates the patient health record and other computer systems/sources to accurately determine diagnosis and procedures codes, MS-DRGs. Codes Inpatient encounters utilizing encoder software and online tools and references, in the assignment of ICD-10 codes, MS-DRG, POA, SOI & ROM assignments.
Communicates effectively with clinical staff, physicians and office staff and Clinical Documentation Specialists (CDS) regarding documentation issues or needs related to Inpatient coding. Formulates compliant clarifications/queries following Trinity Health’s documentation integrity procedures.
Consistently meets or exceeds coding quality and productivity standards established by Revenue Excellence/RHM.
Maintains up-to-date knowledge of changes in coding and reimbursement guidelines and regulations.
Our Commitment to Diversity and Inclusion
Trinity Health is a family of 115,000 colleagues and nearly 26,000 physicians and clinicians across 25 states. Because we serve diverse populations, our colleagues are trained to recognize the cultural beliefs, values, traditions, language preferences, and health practices of the communities that we serve and to apply that knowledge to produce positive health outcomes. We also recognize that each of us has a different way of thinking and perceiving our world and that these differences often lead to innovative solutions.
Our dedication to diversity includes a unified workforce (through training and education, recruitment, retention, and development), commitment and accountability, communication, community partnerships, and supplier diversity.
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