JOB SUMMARY

Performs concurrent medical record reviews to facilitate the highest level of accuracy, quality, and completeness of provider documentation. This is accomplished by medical record review, query process, and reconciliation process. Responsible for assisting in maintaining a financially healthy, productive department, and promoting their own development with an emphasis on evidence-based practice education.

MINIMUM REQUIREMENTS

• Education - Associate degree in Nursing, Health Information Management, or related field of study
• Experience - Two (2) years -adult medical/surgical/critical care/ER/PACU nursing coding or related experience

KNOWLEDGE, SKILLS AND ABILITIES

• Computer skills/ keyboarding skills
• Communication skills
• Interpersonal skills
• Knowledge of IPPS, ICD10 Coding, MS-DRG/APR-DRG and HCPCS coding systems preferred

ESSENTIAL FUNCTIONS

• All team members are expected to be knowledgeable and compliant with Prisma Health’s values: Inspire health. Serve with compassion. Be the difference.
• Conducts concurrent medical record reviews of selected patient health records to address clarity, completeness, consistency and accuracy of clinical documentation.
• Employs the query process as needed to provide accurate documentation reflective of patient’s severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
• Completes the reconciliation process to ensure accurate coding reflective of patient’s severity of illness, risk of mortality, comorbid conditions, length of stay, principal diagnosis, and present on admission (POA) status.
• Develops and maintains supportive, collaborative relationships with providers and health care team members to include education and follow up.
• Stay current with coding guideline changes, changes in treatment modalities, clinical disease indicators, and compliant query policies.
• Serves as a resource for co-workers, providers, and other support departments (coding, case management, quality, nutrition, etc.)
• Assigns a working DRG for health care team discharge planning and CDI use.
• Performs other duties as assigned

SUPERVISORY/MANAGEMENT RESPONSIBILITIES

• This is a non-management job that will report to a supervisor, manager, director or executive.