JDXpert Job Viewer

Education Level

Education Details

Required/
Preferred

High School Diploma or equivalent and Medical Coding Education. In lieu of a medical coding education, an active coding certification is required.

Graduate of a Health Information Technology program.

JDXpert Jobs

HRTMS Job Description Management

NI-Medical Coding Specialist II - Inpatient

J o b D e s c r i p t i o n

JOB INFORMATION
Effective Date:	7/10/2024
Entity:	Illinois
Job Code:	NI-3038AC
Job Title:	NI-Medical Coding Specialist II - Inpatient
FLSA Exemption Status:	Non-Exempt
JOB SUMMARY
The Medical Coding Specialist II - Inpatient is responsible for reviewing documentation in the electronic medical record and assigning and sequencing ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes, in accordance with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and in compliance with ICD-10 Official Coding Guidelines and other regulatory requirements. The Medical Coding Specialist II - Inpatient is proficient with the various Diagnosis Related Groups (DRG) methodologies, including Medicare Severity DRGs (MS-DRGs) and All Patient Refined DRGs (APR-DRGs). The Medical Coding Specialist II - Inpatient codes all case types: including, transplant, major trauma and mortality records, as well as any accounts identified for interim billing or tentative DRGs. The Medical Coding Specialist II - Inpatient participates in the compliant physician query process and will collaborate with the Clinical Documentation Integrity Specialist (CDIS) team regarding clinical validation queries and the DRG reconciliation process as applicable. The Medical Coding Specialist II - Inpatient will partner with the Inpatient Coding Quality Analysts and the Inpatient Coding Supervisor for education and quality monitoring. The Medical Coding Specialist II - Inpatient will assist in any quality metric questions which may arise. This individual may assist with responding to external coding reviews from private payers as well as government contractors. The Medical Coding Specialist II - Inpatient will interact with physicians and other clinicians with minimal supervision as it pertains to coding and documentation.

ESSENTIAL DUTIES

•	Review, analyze and interpret the entire electronic medical record for the current admission to identify all diagnoses and procedures documented during the admission.
•	Determine and assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology and pathophysiology/disease processes.
•	Identify cases with clinical indicators that may require provider documentation clarification and/or specificity in order to accurately assign codes; collaborate with CDIS team as part of the clinical documentation validation and physician query workflows.
•	Analyze code assignment and sequence to assure proper MS DRG assignment; sequence codes in compliance with ICD-10 Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS) and other regulatory requirements to accurately assign the DRG.
•	Analyze medical record documentation for optimum severity of illness and risk of mortality scores.
•	Confirm Admission-Discharge-Transfer (ADT) information and correct when necessary.
•	Suggest and assist with workflow process improvements as appropriate. Participate in coding quality and productivity processes.
•	Identify topics of high priority for training and clarification and refer to the Supervisor/Manager.
•	Keep abreast of annual and periodic updates to the ICD-10 coding system and regulations to provide expert coding advice to colleagues.

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned. ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

Age Specific Competency (Clinical jobs only)
X	Non-Clinical

JOB REQUIREMENTS

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY.

Knowledge, Skills, and Abilities
•	Knowledge of, but not limited to, current Official Coding Guidelines and methodologies, MS-DRGs, APR-DRGs, the ICD-10-CM/PCS coding systems and conventions.
•	Extensive knowledge of medical terminology, anatomy and pathophysiology, pharmacology and ancillary test results.
•	In-depth knowledge of complex medical and coding concepts encountered in an Academic Medical Center.
•	Knowledge of coding systems and regulatory requirements of Inpatient Prospective Payment System (IPPS).
•	Proficiency with encoder software and other coding applications/tools.
•	Strong communication skills (interpersonal, verbal and written).
•	Serve as a subject matter expert to Clinical Documentation Improvement Specialists, colleagues and clinicians.
•	Strong organizational and analytical thinking skills.
•	Demonstrates critical thinking skills, and ability to interpret, assess, and evaluate provider documentation.
•	Proficient with Microsoft Office applications (Outlook, Word, Excel).
•	Self-motivated and demonstrated capacity to work independently without close supervision. This position has the potential to work remotely.
•	Must be able to work flexible hours which may include weekends as required to meet business needs.
•	Ability to quickly analyze a situation, problem solve and prioritize.
•	Familiarity with the external reporting aspects of healthcare.
•	Knowledge of external auditing programs; ex.: Recovery Audit Contractor (RAC), Office of the Inspector General (OIG), third-party payors.

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

Physical Demands
A thorough completion of this section is needed for compliance with legal standards such as the Americans with Disabilities Act. The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Physical Demand	Continuous Over 70%	Frequent 40% - 69%	Occasional 15% - 39%	Rarely Up to 15%
Standing				X
Walking				X
Climbing				X
Bending				X
Crouching				X
Pushing / Pulling				X
Carry				X
Fine Hand / Eye Coordination	X
Color Discrimination				X
Hearing Ability		X
Lifting / Lowering 1 -15 lbs.		X
15 - 30 lbs.				X
30 - 50 lbs.				X


Over 50 lbs.	UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Physical Demands
While performing the duties of this job, the associate is required to work within the selected working environments.
Physical Demands	Continuous Over 70%	Frequent 40% - 69%	Occasional 15% - 39%	Rarely Up to 15%
Concentration on Detail		X
Attention Span of 1 + Hours on a Task			X
Ability to Remember Multiple Tasks		X
Oral Communication		X
Written Communication		X

Physical Demands
Physical Demands	Continuous Over 70%	Frequent 40% - 69%	Occasional 15% - 39%	Rarely Up to 15%
Exposure to Blood and Body Fluids				X
Exposure to Toxins, Cytotoxins, Poisons				X
Exposure to Extreme Heat, Cold, Temp Fluctuations				X
Exposure to Hazardous Chemicals				X
Exposure to Radiation				X

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.
THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.