JOB SUMMARY
The Coding Specialist III is responsible to review and code inpatient and outpatient University of Texas Southwestern Medical Center (UTSW) medical records. The UTSW medical records are maintained in electronic format and will be coded according to current coding guidelines, and in compliance with organizational, departmental, and regulatory requirements. The Coding Specialist III is identified as the highest level coding subject matter expert due to education, training, and experience and as such will receive coding assignments in accordance with that level of expertise. Additionally, the Coding Specialist III may be asked to mentor and proctor employees at the Coding Specialist I and II levels.
ESSENTIAL FUNCTIONS
Job Duties
- Responsible for coding concurrent or retrospective inpatient accounts using ICD-10 CM/PCS, in compliance with the Official Coding Guidelines and conventions.
- Accurately identifies most appropriate Admit Diagnosis, Principal Diagnosis, and Procedure for the DRG, and all secondary diagnoses to accurately reflect all CC/MCC's, POA status, and Severity of Illness and Risk of Mortality.
- Accurately abstracts required data elements including, discharge disposition, discharge destination, procedure dates and physician(s), and other designated data.
- a) Identifies when a physician query is appropriate for further clarification. b) Recognizes when the documentation is missing or incomplete and routes appropriately. c) Completes review and final coding when query and/or documentation is available.
- Maintain the Quality Standards set by UTSW/HIM Coding.
- Maintain the Productivity Standards set by UTSW/HIM Coding.
- Mentor/train on designated coding service lines as requested to ensure quality.
- Maintains an expert level of knowledge of coding related guidelines and practices.
- Other duties as assigned
QUALIFICATIONS
Education and Experience
Required
- Experience
3 years to 5 years acute hospital based coding experience.
Experience working in a remote environment required for PRN Coders.
An equivalent combination of education and experience may be considered.
- Licenses and Certifications
(RHIA) REGD HEALTH INFO ADMINIST Upon Hire or
(RHIT) REGD HEALTH INFO TECHNOLO Upon Hire or
(CCS) CERT CODING SPECIALIST Upon Hire
Preferred
- Education
Associate's Degree in Health Information Management and/or closely related field or
Bachelor's Degree in Health Information Management and/or closely related field
- Experience
Experience working in a remote environment preferred.
Knowledge, Skills and Abilities
- Work requires ability to comprehend, understand, and follow established policies, procedures, and other guidelines of some complexity.
- Work requires ability to handle multiple tasks, show initiative, and adjust to changes as appropriate under a stressful environment.
- Work requires ability to perform in a conservative, fast-paced, and quality driven environment.
- Work requires ability to report and problem solve using discretion, judgment, and professionalism.
- Work requires excellent customer service, interpersonal, and communication skills (verbal and written).
- Work requires organizational skills along with a high level of accuracy and attention to detail.
- Work requires self-motivation, maturity, and being a team player.
- Work requires strong analytical and critical thinking skills.
PHYSICAL DEMANDS/WORKING CONDITIONS
- Working Conditions
Office Setting
PACT STATEMENT
- P-Problem Solving: Employees take ownership in solving problems effectively, efficiently, and to the satisfaction of customers, or managers. They show initiative in addressing areas of concern before they become problems.
- A-Ability, Attitude and Accountability: Employees exhibit ability to perform their job and conduct themselves in a professional and positive manner reflecting a professional environment readily assuming obligations in a dependable and reliable manner.
- C-Communication, Contribution, and Collaboration: Who are our Customers? Anyone who requests our help, needs our work product, or receives our services. Employees focus on customer service with creative solutions while improving the customer experience through clear, courteous, and timely delivery and communication. Sharing ideas with others helps expand our contribution to department goals.
- T-Teamwork: Employees work to contribute to the department's success by supporting co-workers, promoting excellence in work product and customer service, and in maintaining a satisfying, caring environment for each other.
Security
This position is security-sensitive and subject to Texas Education Code 51.215, which authorizes UT Southwestern to obtain criminal history record information.
EEO Statement
UT Southwestern Medical Center is committed to an educational and working environment that provides equal opportunity to all members of the University community. As an equal opportunity employer, UT Southwestern prohibits unlawful discrimination, including discrimination on the basis of race, color, religion, national origin, sex, sexual orientation, gender identity, gender expression, age, disability, genetic information, citizenship status, or veteran status.