HIM Coder CCS RHIT or RHIA preferred - 1st Shift - (Full Time, Remote)

At Virtua Health, we exist for one reason – to better serve you. That means being here for you in all the moments that matter, striving each day to connect you to the care you need. Whether that's wellness and prevention, experienced specialists, life-changing care, or something in-between – we are your partner in health devoted to building a healthier community. 
 
If you live or work in South Jersey, exceptional care is all around. Our medical and surgical experts are among the best in the country. We assembled more than 14,000 colleagues, including over 2,850 skilled and compassionate doctors, physician assistants, and nurse practitioners equipped with the latest technologies, treatments, and techniques to provide exceptional care close to home. A Magnet-recognized health system ranked by U.S. News and World Report, we've received multiple awards for quality, safety, and outstanding work environment.

In addition to five hospitals, seven emergency departments, seven urgent care centers, and more than 280 other locations, we're committed to the well-being of the community. That means bringing life-changing resources and health services directly into our communities through our Eat Well food access program, telehealth, home health, rehabilitation, mobile screenings, paramedic programs, and convenient online scheduling. We're also affiliated with Penn Medicine for cancer and neurosciences, and the Children's Hospital of Philadelphia for pediatrics.

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Summary:

Codes and abstracts hospital medical records (including Inpatients, Observation, Outpatient Surgery, Invasive Outpatients, and Emergency Department) for diagnostic and procedural coding. 

Utilizes federal, state procedures/guidelines to assure accuracy of coding and abstracting and productivity standards. 

Collaborates with medical staff and clinical documentation improvement (CDI) staff to clarify documentation. 

Maintains performance in accordance with corporate compliance requirements as it pertains to the coding and abstracting of medical records, as well as Diagnosis Related Group (DRG) assignment.

Position Responsibilities:

Accurately reviews each record and knowledgeably utilizes ICD-10-CM, ICD-10-PCS, CPT-4, and encoder to accurately code all significant diagnoses and procedures according to American Hospital Association (AHA), American Health Information Management Association (AHIMA), Uniform Hospital Discharge Data Set (UHDDS) hospital specific guidelines and rules/conventions. 

Records coded include Inpatient, Observation, Outpatient Surgery, Invasive Outpatients, and Emergency Department. Sequences principal (or first-listed) diagnosis and principal procedures according to documentation found in the medical records and UHDDS definitions.

Utilizes ongoing knowledge and reference material regarding DRGs to validate DRG assignments.

Accurately utilizes written federal and state regulations and written guidelines regarding definitions and prioritizing of abstract data elements to assure uniformity of database. 

Records abstracted include Inpatient, Observation, Outpatient Surgery, Invasive Outpatients, and Emergency Department. Verifies and/or abstracts required data into computer system according to procedure.  Utilizes equipment and processes appropriately, to ensure efficient coding and abstracting; utilizes the established downtime procedures as needed.

Participates in maintaining DNB and accounts receivable goal.

Maintains department level competencies.  Participates in performance improvement activities.

Position Qualifications Required / Experience Required:

Minimum of two years inpatient records coding experience or equivalent.

Ability to perform functions in a Microsoft Windows environment.

Ability to be detailed oriented and perform tasks at a high level of accuracy.

Ability to make sound decisions.

Demonstrate good communication and team work skills.

Previous experience with an electronic legal health record system preferred.

Required Education:

High School Diploma or GED required.

Knowledge of Anatomy & Physiology/ Medical terminology required.

Coding education preferred or equivalent in years of experience.

Training/Certifications/Licensure:

AHIMA Certification:  Certified Coding Specialist (CCS) Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT) preferred