IP Facility Coder
Posted on: May 27, 2023
To independently and efficiently perform the responsibilities
assigning accurate diagnosis and procedures codes to the patients
health information records for: Emergency Department (ED),
Ambulatory Surgical Center (ASC), Hospital Ambulatory Surgical
Center (HAS), Observations (OBS), Inpatient (IP) and other selected
facility records. Maintain an acceptable level of performance in
quality and productivity for ICD-10-CM, ICD-10-PCS, and HCPCS/CPT
classification and nomenclature systems. All work will be carried
out in accordance with the: International Classification of
Diseases - Official Coding Guidelines for coding and reporting as
established by the Centers for Medicare and Medicaid Services (CMS)
and the National Center for Health Statistics (NCHS); American
Medical Association (CPT); National Correct Coding Initiative
(NCCI); Uniform Hospital Discharge Data Set (UHDDS), Medicaid
(OMAP), and Kaiser Permanente organization/institutional coding
directives. Ability to communicate with physicians in order to
obtain clarification for diagnoses/procedures. Ability to
understand the clinical content of the health record and abstract
the data in the patient health information record data as well as
perform other duties assigned. The position requires the new coder
to be on-site for one (1) week training or until they meet the
departments expectations.Essential Responsibilities:
- Proficient in medical record review and translating clinical
information into coded data. Identify and assign appropriate codes
for diagnoses, procedures and other services rendered, while also
validating any Computer Assisted Coded (CAC) assignments for dual
coding. Utilizing the Code Base Charge Trigger system (CBCT) and
OPTUM 360 EncoderPRO software system for professional surgical
services, analyzing and maintaining systems accuracy, validity and
meaningfulness for both professional and facility services.
Utilizes electronic patient data system and clinical information
system (EpicCare) to access patient encounter information.
Abstracts and enters clinical data elements as defined by the needs
of the organization. Identifies and assigns principal diagnosis and
procedure codes, sequencing them as needed for proper Ambulatory
Payment Classification (APC), Medicare Severity-Drug Related Group
(MS-DRG), All Patients Refined Diagnosis Related Groups (APR-DRG)
assignment, utilizing applicable coding conventions. Demonstrates
knowledge and understand of CMS HCC Risk Adjustment coding.
Routinely performs chart analysis to identify areas of the medical
record that contain incomplete, inaccurate or inconsistent
documentation. Reviews and verifies chart information (i.e. POS,
attending provider). Assesses and inputs data. Reviews and verifies
component parts of medical records to ensure completeness and
accuracy of diagnostic and therapeutic procedures that must conform
to CMS coding rules and guidelines. Meets and maintains department
standards 95% for productivity and quality. Coding Auditor Senior
spends a minimum of 80% of work time assigning codes to Inpatient
- Fully utilizes resources available such as, Coding Clinic and
CPT Assistant to research issues to apply coding guidelines.
Identifies coding concerns and informs supervisors, managers as
appropriate. Utilizes query process when appropriate. Assists in
implementing solutions to reduce back-end coding errors. Stays
current on coding and regulatory publications, attends workshops to
stay abreast of current issues, trends, changes in the laws and
regulations governing medical record coding and documentation to
mitigate the risk of fraud and abuse and to optimize revenue
- May assist with special projects. Maintain confidentiality and
effective working relationships with staff. Communicate in a clear
and understandable manner, exercises independent judgment. Reviews
annual ICD-10 Official Guidelines for Coding, along with review of
quarterly Coding Clinic and monthly CPT Assistant. Performs as a
team member of Facility Coding Services, and actively participates
with peers coding in-services, staff meetings, reporting of
performance measures, and quality outcome monitors. May participate
in development of organizational procedures. Attends and
participates in selected national and regional coding education
sessions. Perform other duties as assigned.Basic Qualifications:
- Minimum five (5) years experience in coding with four (4) years
inpatient facility coding or minimum four (4) years in the Kaiser
Coding Auditor position with proficiency in inpatient coding.
- High School Diploma or General Education Development (GED)
required. -License, Certification, RegistrationThe candidate must
have 1 from the following list:
- Registered Health Information Technician Certificate
- Coding Specialist Certificate
- Registered Health Information Administrator Certificate
- Previous experience with EMR patient documentation system with
intermediate knowledge and skill in the use of a computer.
- Advance knowledge of disease processes, diagnostic and surgical
procedures, ICD-10-CM, ICD-10-PCS, HCPCS/CPT classification
systems, health information/medical record department
responsibilities with knowledge of government regulations and areas
of scrutiny for potential fraud and abuse issues.
- Advanced knowledge of medical terminology, pharmacology and
medial coding principles for ICD-10-CM, ICD-10-PCS, HCPCS/CPT and
- Fluent in English, demonstrating skill and proficiency in oral
and written communication.
- Skills in time management, organization and analytical
- Ability to manage a significant workload and to work
efficiently under pressure meeting established deadlines with
- Ability to use independent thought and judgement.
- Abides by the Standards of Ethical Coding as set for by the
American Health Information Management Association (AHIMA).
- Meets and maintains department standard for performance,
productivity and quality.
- Department will furnish final candidate a coding skill test.
The candidate will be required to pass with a 75% or better on the
- Academic knowledge and working experience performing coding and
abstracting responsibilities in health information/medical record
services. -Preferred Qualifications:
- Minimum five (5) years of experience in health
information/Medical record environment, with facility coding
experience that includes Medicare reimbursement guidelines.
- Degree in Health Information Management.
- Proficient knowledge and skill in the use of a computer and
related system and software to include: EMR(s), Microsoft Office
Suite and other software programs.
- Ability to evaluate, analyze, develop information regarding
mathematical statistics and percentages that compare finding trends
and outcomes related to productivity and /ore medical record
- Extensive knowledge of ICD-10 coding guidelines; with knowledge
and demonstrated understand of CMS HCC Risk Adjustment coding and
data validation requirements.PrimaryLocation :
Oregon,Clackamas,Regional Process CenterHoursPerWeek : 40Shift :
DayWorkdays : Mon, Tue, Wed, Thu, FriWorkingHoursStart : 08:00
AMWorkingHoursEnd : 04:30 PMJob Schedule : Full-timeJob Type :
StandardEmployee Status : RegularEmployee Group/Union Affiliation :
NUE-NW-02-NUE-Non Union EmployeeJob Level : Individual
ContributorJob Category : Medical Records,Health Information
ManagementDepartment : Portland Regional Process Ctr - Centralized
Medical Records - 1001Travel : NoKaiser Permanente is an equal
opportunity employer committed to a diverse and inclusive
workforce. Applicants will receive consideration for employment
without regard to race, color, religion, sex (including pregnancy),
age, sexual orientation, national origin, marital status, parental
status, ancestry, disability, gender identity, veteran status,
genetic information, other distinguishing characteristics of
diversity and inclusion, or any other protected status.
Keywords: Kaiser, Portland , IP Facility Coder, Other , Wilsonville, Oregon
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