NHRMC, established in 1967 in Wilmington, NC, is recognized as a preeminent healthcare organization focused on leading our community to outstanding health. We have an 855 bed network of hospitals and multi-specialty physician group practices with more than 200 physicians. With a network of primary, specialty, neighborhood clinics and regional medical centers; you will find our culture is the very definition of best in practice. Join us and find out how many ways NHRMC offers you the chance to focus on what really matters - our patients and community.
About the Job
Location: NHRMC Business Center A
Department: Coding - HIM
Full Time Equivalent: FTE: 1.000000
Work Type: 64 to 80 Hours Pay Period
Work Schedule: STD HRS - Standard-Exe or Office w flex
Exempt from Overtime: Exempt: No
What You'll Do
Under the general direction of the Manager of Coding and Clinical Abstracting, this specialist is responsible for accurate coding of all ancillary and clinic visit diagnosis, procedures, and charges working from the appropriate documentation in the medical record of the patient. Classification systems include ICD-9-CM, ICD-10-CM and CPT-4. This specialist performs ongoing medical record reviews to assess completeness and timeliness of information to support services billed. This person is responsible for calculating and posting charges for facility levels, injections and infusions, and procedures for designated service areas. He/She must be knowledgeable about charge assignment, bundling, and appropriate modifier usage. The Coder I works with physicians and professional staff to obtain any necessary clarification concerning diagnosis and procedures and for monitoring reports such as the Discharges Not Final Billed (DNFB) daily schedules and timely filing lists. He/She must have a thorough understanding of facility charging guidelines, APC reimbursement, CCI rules and edits, and application of Local and National Coverage Determinations (LCD/NCDs). This person requires little supervision and performs all work independently, with a high degree of autonomy. All work is carried out in accordance with the department’s approved policies and procedures. This position is an advanced level technical position within the Coding Department.
1. Codes all diagnoses and procedures for ancillary and clinic services according to the appropriate classification system for that category of patient encounter, and in accordance with provisions of the Uniform Hospital Discharge Data Set as well as the interpretation of these provisions as issued by the American Hospital Association and American Health Information Management Association and all governmental and private Third Party rules and regulations.
2. Abstracts patient information from records of all assigned accounts and enters appropriate data elements into the computerized abstracting system.
3. Calculates and posts charges for facility levels, injections and infusions, and procedures for designated service areas. Adds appropriate modifiers and reviews accounts for charge errors. Performs or refers charge corrections to appropriate resource to ensure accurate billing.
4. Consistently meets (100%) coding productivity target and accuracy requirements (95% or higher).
5. Completes continuing education as required to maintain competency and credentials (if applicable) as well as to stay current with coding rules and guidelines.
6. Collaborates with physicians and other direct patient care professionals in questions regarding level of detail for diagnostic entries, according to the organization’s guidelines.
7. Promotes public relations through prompt and courteous service.
8. Fosters respect for patient privacy by maintaining confidentiality in all phases of work.
9. Performs those duties necessary to ensure all accounts are processed accurately and efficiently.
10. Maintains a successful working relationship with employees, medical staff, and other departments.
* High School Diploma
Experience: At least one year coding/abstracting required, coding experience in an acute care setting, as well as experience with encoding software and electronic medical records preferred. Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
Performs other duties as assigned.
Individual will possess commensurate combination of education, experience and qualifications.
This position description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications which may be required of the employee assigned to the position. Depending on the location of the job, duties may vary. Receipt of the job description does not imply nor create a promise of employment, nor an employment contract of any kind; my employment with the Company is at will.
- Member Top 100 Hospitals – In 2016 NHRMC was recognized as a Top 100 Hospital demonstrating significant investment and financial sustainability for the communities we serve.
- Newsweek's 2020 list of Best Maternity Care Hospitals - NHRMC Betty H. Cameron Women's & Children's Hospital was named as a Best Maternity Care Hospital by Newsweek.
- Forbes America’s Best Large Employers 2018 and 2019- Link
- Becker’s 150 Top Places to Work in Healthcare- Link
- Healthgrades Outstanding Patient Experience
Consider a career at NHRMC and become part of this award winning team!