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POST DATE 9/7/2016
END DATE 7/19/2017
Northwestern Memorial Healthcare
JOB DESCRIPTIONThe Coder/Abstractor reflects the mission, vision, and values of Northwestern Memorial, adheres to the organization's Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. Utilizing technical coding expertise, reviews medical records both electronic and paper to determine the appropriate ICD-9-CM codes for inpatient records and assigns CPT-4 codes when necessary for outpatient records. The coding process has a direct impact on the Hospital's reimbursement and revenue cycle. Reviews inpatient charts (paper & electronic) by reading and interpreting physician documentation included in but not limited to: H&P, Progress Notes, Physician Orders, OR Report/Path Report as well as various diagnostic test results to determine the principal diagnosis (reason for admission), secondary diagnoses and invasive procedures. Utilizes technical coding expertise to assign the appropriate ICD-9-CM codes to inpatient records. Reviews outpatient same day surgery records (paper & electronic) to determine the reason for encounter/visit, secondary diagnoses and invasive procedures by reading and interpreting physician documentation included in but not limited to: H&P, Progress Notes and OR Report/Path Report. Utilizes technical coding expertise to assign the appropriate ICD-9-CM and CPT-4 codes to outpatient records. Reviews H&P for clinical pertinence and enters data into abstracting system (ClinTrac). Assigns appropriate codes utilizing encoder software (3M). Identifies adverse drug reaction(s) and codes appropriately. Reports unusual incidents to Risk Management, i.e., patient fall, return to the OR. AA/EOE
* RHIT - Registered Health Information Technician or RHIA - Registered Health Information Administrator or CCS - Certified Coding Specialist or eligible
* 1 year experience coding inpatient and or observation/ambulatory surgery medical records.
* 3 years experience coding inpatient and or observation/ambulatory surgery medical records.