OhioHealth
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Trauma Coder
role at
OhioHealth .
We are more than a health system. We are a belief system.
We believe wellness and sickness are both part of a lifelong partnership, and that everyone could use an expert guide. We work hard, care deeply and reach further to help people uncover their own power to be healthy. We inspire hope. We learn, grow, and achieve more— in our careers and in our communities.
Job Description Summary This position performs coding and abstracting functions for Trauma Patients including Emergency Department, Observation, Observation in a bed and the inpatient setting.
Responsibilities And Duties
60% of time:
Assign appropriate admit, principal and secondary diagnoses and/or procedure codes by reviewing documentation and applying coding guidelines while maintaining 95% quality and meeting minimum Coder productivity requirements.
Assign Present on Admission (POA) indicator to all inpatient account diagnoses as required.
Assign ICD-10 diagnosis/procedure codes and AIS scoring at minimum standards of 95% quality.
Review diagnosis and CC/MCC for maximum SOI/ROM; demonstrate clinical understanding of laboratory and radiology values; apply quality outcome indicators; collaborate with CDS to improve physician documentation and case mix index; assign principal diagnosis accurately at least 95%.
Monitor and appropriately assign codes when appropriate.
Recognize when additional clarification from physician is needed and obtain it.
Assist providers and supervisors with reviewing accounts denied by NTDB and other governing bodies to support original coding.
35% of time:
Abstract all data elements necessary to complete NTDB and TQIP requirements and meet hospital‑reporting requirements; follow department policy for follow‑up and physician query; identify problem cases in EPIC and forward to appropriate staff.
5% of time:
Verify demographics, account number, service, and identify missing or incorrect forms in each record.
Minimum Qualifications
Associate's degree or 1-3 years of coding experience in an acute care/hospital setting.
Specialized knowledge of AIS Scoring, ICD‑10CM and PCS classification systems, advanced anatomy & physiology, pathophysiology, pharmacology, medical terminology, inpatient documentation schemes; knowledge of hospital acquired conditions (HAC), present on admission (POA), severity of illness (SOI), risk of mortality (ROM), and quality outcome indicators.
Knowledge of operative reports, clinical lab, and radiology results for physician queries; knowledge of clinical documentation improvement programs; knowledge of NTDB and TQIP abstracting elements.
Work Details Shift:
Day Scheduled Weekly Hours:
40 Department:
Trauma Services
Equal Employment Opportunity OhioHealth is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations. OhioHealth does not discriminate against associates or applicants because of race, color, genetic information, religion, sex, sexual orientation, gender identity or expression, age, ancestry, national origin, veteran status, military status, pregnancy, disability, marital status, familial status, or other characteristics protected by law. Equal employment is extended to all persons in all aspects of the associate–employer relationship including recruitment, hiring, training, promotion, transfer, compensation, discipline, reduction in staff, termination, assignment of benefits, and any other term or condition of employment.
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Trauma Coder
role at
OhioHealth .
We are more than a health system. We are a belief system.
We believe wellness and sickness are both part of a lifelong partnership, and that everyone could use an expert guide. We work hard, care deeply and reach further to help people uncover their own power to be healthy. We inspire hope. We learn, grow, and achieve more— in our careers and in our communities.
Job Description Summary This position performs coding and abstracting functions for Trauma Patients including Emergency Department, Observation, Observation in a bed and the inpatient setting.
Responsibilities And Duties
60% of time:
Assign appropriate admit, principal and secondary diagnoses and/or procedure codes by reviewing documentation and applying coding guidelines while maintaining 95% quality and meeting minimum Coder productivity requirements.
Assign Present on Admission (POA) indicator to all inpatient account diagnoses as required.
Assign ICD-10 diagnosis/procedure codes and AIS scoring at minimum standards of 95% quality.
Review diagnosis and CC/MCC for maximum SOI/ROM; demonstrate clinical understanding of laboratory and radiology values; apply quality outcome indicators; collaborate with CDS to improve physician documentation and case mix index; assign principal diagnosis accurately at least 95%.
Monitor and appropriately assign codes when appropriate.
Recognize when additional clarification from physician is needed and obtain it.
Assist providers and supervisors with reviewing accounts denied by NTDB and other governing bodies to support original coding.
35% of time:
Abstract all data elements necessary to complete NTDB and TQIP requirements and meet hospital‑reporting requirements; follow department policy for follow‑up and physician query; identify problem cases in EPIC and forward to appropriate staff.
5% of time:
Verify demographics, account number, service, and identify missing or incorrect forms in each record.
Minimum Qualifications
Associate's degree or 1-3 years of coding experience in an acute care/hospital setting.
Specialized knowledge of AIS Scoring, ICD‑10CM and PCS classification systems, advanced anatomy & physiology, pathophysiology, pharmacology, medical terminology, inpatient documentation schemes; knowledge of hospital acquired conditions (HAC), present on admission (POA), severity of illness (SOI), risk of mortality (ROM), and quality outcome indicators.
Knowledge of operative reports, clinical lab, and radiology results for physician queries; knowledge of clinical documentation improvement programs; knowledge of NTDB and TQIP abstracting elements.
Work Details Shift:
Day Scheduled Weekly Hours:
40 Department:
Trauma Services
Equal Employment Opportunity OhioHealth is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations. OhioHealth does not discriminate against associates or applicants because of race, color, genetic information, religion, sex, sexual orientation, gender identity or expression, age, ancestry, national origin, veteran status, military status, pregnancy, disability, marital status, familial status, or other characteristics protected by law. Equal employment is extended to all persons in all aspects of the associate–employer relationship including recruitment, hiring, training, promotion, transfer, compensation, discipline, reduction in staff, termination, assignment of benefits, and any other term or condition of employment.
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