Medical Coder @ Optum

Under direct supervision, the Inpatient Coder is responsible for accurate coding of the professional services (diagnoses, procedures, and modifiers) from medical records in a hospital/clinic setting. Analyzing the medical record, assigning ICD-10-CM, and ICD-10-PCS codes with appropriate modifiers. Medical coding is performed in accordance with the rules, regulations and coding conventions of ICD-10-CM Official Guidelines for Coding and Reporting, ICD-10-PCS guidelines for reporting surgical services, Coding Clinic articles published by the American Hospital Association, and Client Coding Guidelines.

Primary Responsibilities:

• Identify appropriate assignment of ICD - 10 - CM and ICD - 10 - PCS Codes for inpatient services provided in a hospital setting and understand their impact on the DRG with reference to CC / MCC, while adhering to the official coding guidelines and established client coding guidelines of the assigned facility
• Abstract additional data elements during the Chart Review process when coding, as needed
• Adhere to the ethical standards of coding as established by AAPC and / or AHIMA
• Ability to code 1.5-2.5 charts per hour and meeting the standards for quality criteria
• Needs to constantly track and implement all the updates of AHA guidelines
• Provide documentation feedback to providers and query physicians when appropriate
• Maintain up - to - date Coding knowledge by reviewing materials disseminated / recommended by the QM Manager, Coding Operations Managers, and Director of Coding / Quality Management, etc.
• Participate in coding department meetings and educational events
• Review and maintain a record of charts coded, held, and / or missing
• An ideal team player who can work in a large group and provide inputs to the team for betterment of the team in terms of quality and productivity
• Under general supervision, organizes and prioritizes all work to ensure that records are coded and edits are resolved in a timeframe that will assure compliance with regulatory and client guidelines
• Adherence with confidentiality and maintains security of systems. Compliance with HIPAA policies and procedures for confidentiality of all patient records
• Demonstrates knowledge of security of systems and associated policies and procedures for maintaining the security of the data contained within the systems.

Required Qualifications:

• E/M IP ,Surgery & IPDRG coders can apply for this role
• E/M IP ,Surgery will be considering and will provide Cross training IP Team
• 1+ years in multispecialty IPDRG Coding
• 1+ years of Acute Care Inpatient medical coding experience (hospital, facility, etc.)
• ICD - 10 (CM & PCS) and DRG coding experience
• Experience with working in a level I trauma center and / OR teaching hospital with a mastery of complex procedures, major trauma ER encounters, cardiac catheterization, interventional radiology, orthopedic and neurology cases, and observation coding

Preferred Qualification:

• Life Science or Allied Medicine Graduates with certification from AAPC or AHIMA. CIC certification.