Non-Clinical – Health and Information Management/Inpatient Coder

**AGENCIES MUST HAVE AN AUDITOR AVAILABLE ON STAFF TO AUDIT THE WORK DURING THE PROBATIONARY PERIOD. AGENCIES MUST BE AGREEABLE TO THE BELOW AUDITOR EXPECTATIONS**

Subcontracting agencies will provide auditing support for their contracted coders as follows:
• Accuracy expectation of 95% for coding.
• Initial pre-bill audit of 20 charts, followed by an ongoing audit of 10 charts per month per coder; audit results to be provided to the client.
• After 90 days, a minimum audit of 10% of cases per month is required to ensure speed and accuracy expectations are being met; audit results to be provided to the client.
• Monthly productivity reports are required, with tracking tied to specific accounts to allow for client validation.

**CANDIDATES MUST HAVE TRAUMA CODING EXPERIENCE ON THEIR RESUME. PHYSICAN BILLING CODERS ARE NOT QUALIFIED. INPATIENT MEDICAL RECORDS FROM A HOSPITAL ENVIRONMENT IS REQUIRED EXPERIENCE**

Job Title: Sr Inpatient Coder – Trauma Experience Required
Location: Remote (University of Maryland Corporate Offices). Must be based in EST or CST hours.
Schedule: Full-time; Operating hours are 6AM-6PM EST. Flexible to work 8 or 10 hour shifts (40 hours per week) during operating timeframe.
Conversion: Yes, candidates MUST be open to converting to perm (cannot hire from Alaska, California, or Hawaii)
Auditor Requirement: Agencies must have an auditor on staff to audit contractor’s work during contract period
Equipment: Facility will NOT provide equipment. Contractors must have their own equipment for contract duration

JOB DESCRIPTION

Under direct supervision, accurately codes hospital inpatient accounts for the purpose of appropriate reimbursement, research, statistics and compliance to federal and state regulations in accordance with established ICD-10-CM/PCS coding classification systems.

REQUIREMENTS:
*High School graduate or equivalent.
*Formal ICD-10-CM and CPT training
*Associates or Bachelor’s degree preferred.
*Minimum of three years ICD-10-CM/ICD-10-PCS coding and abstracting experience with at a Level 1 Trauma and Rehab hospital.
*MUST have Trauma Coding experience
*4 years of experience with coding inpatient hospital medical records required.
*One of the following required: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Inpatient Coder (CIC)

Responsibilities and Tasks:

*Serves as a clinical coding subject matter expert, and utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed.
*Analyzes, codes and abstracts complex inpatient cases such as trauma, rehab, neurology, critical care, etc. utilizing the ICD-10-CM and ICD-10-PCS nomenclature to ensure accurate APR-DRG/SOI/ROM and POA assignment.
*Utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed.
*Collaborates with other senior coders (and the other coding staff) with sharing coding information and providing coding advice to colleagues regarding complex cases to be coded.
*Monitors assigned work on a daily basis in order to facilitate the billing process within the established timeframes. Codes and abstracts records within timeframes established for each patient type.
*Maintains coding quality accuracy rate of ***%.
*Maintains productivity rate of ***%.
*Communicates with various departments within the hospitals regarding billing and registration issues. Refers any problems to management timely, providing clear details. Compose appropriate coding queries, work collaboratively with CDI, understand Potentially Preventable Complications (PPC’s)/Maryland Hospital Acquired Conditions (MHAC’s), and Prevention Quality Indicators (PQI’s) and their impact.
*Communicates with the Auditing team to discuss audit findings and working collaboratively in making sure that all accounts are coded appropriately and meet standards of compliance
*Complies with AHIMA standards of ethical coding and coding compliance guidelines.
*Demonstrates support and compliance with University of Maryland Medical System mission, vision, values statement, goals and objectives and policies. Performs other duties or projects such as coding corrections as assigned by the manager.