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UF Health

Coder III | Health Information Management | Full-time | Days (REMOTE)

UF Health, Saint Augustine, Florida, United States, 32095

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Coder III | Health Information Management | Full-time | Days (REMOTE) Join to apply for the Coder III | Health Information Management | Full-time | Days (REMOTE) role at UF Health

Overview Full-time Monday through Friday 8:00am to 4:30pm. Remote (must live in Florida).

The Coder III position assigns diagnoses and procedure codes to inpatient medical records.

Responsibilities

Assigns correct ICD-10-CM code to all diagnoses and correct ICD-10-PCS code to all procedures documented in the medical record.

Thoroughly reviews the entire medical record to retrieve proper documents (discharge summary, progress notes, operative report, pathology report, anesthesia report, etc.) to provide coding specificity.

Assesses documentation to ensure it is adequate and appropriate to support the diagnoses and procedures to be abstracted.

Selects the principal diagnosis and procedure according to the Uniform Hospital Discharge Data Set definitions and coding rules published in Coding Clinic.

Sequences codes within regulatory guidelines for correct DRG assignment.

Abstracts attending and operating physicians in the Sunrise Record Manager abstracting system.

Verifies and corrects appropriate discharge disposition.

Maintains knowledge of encoder use to assist in code assignment.

Queries physicians as necessary to resolve documentation discrepancies and maintain positive relationships to improve clinician documentation practice.

Maintains knowledge of the prospective payment system and updates to codes/DRGs; adheres to official guidelines (AHA, AHIMA, CMS, NCHS) and ICD-9-CM conventions; stays current with Medicare policies.

Qualifications

Education / Training: High School Diploma/Equivalent

Preferred: Graduate of Health Information Management Program

Experience: 5 to 7 years Hospital Medical Record Coding

Certifications/Licenses/Registration: Any AAPC or AHIMA Medical Coding Certification

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