Job Description

Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Health Information Management

Job Family

Professional

Work Shift

Days (United States of America)Under the general direction of the HIM Coding Director, the Senior Clinical Coding Specialist is responsible for accurate coding of diagnosis and procedures for all record types, working from the appropriate documentation in the medical record of the patient. The Senior Clinical Coding Specialist is responsible for training and orienting new employees to policies and procedures, abstracting and coding, and the use of EPIC workflows. Serves as a primary resource to coders for guideline clarification and appropriate code assignment. The Senior Coding Specialist is responsible for assisting with backlog regardless of financial class or inpatient/outpatient status as directed by coding leadership. The Senior Coding Specialist plays an active role in meeting the organization’s financial goals. Possesses an in-depth knowledge of IPPS and OPPS reimbursement and the application of Coding Guidelines, Local and National Coverage Determinations (LCD/NCDs). This position is an advanced level certified technical position within the Coding Department.

Major Job Functions

The following is a summary of the major essential functions of this job. The incumbent may perform other duties, both major and minor, that are not mentioned below. In addition, specific functions may change from time to time:

• Trains and orients new employees to job duties, workflow, policies and procedures, coding and abstracting, encoding software and daily activities

• Monitors established workflows and presents recommendations to coding leadership for updates to policies and procedures.

• Assists with coding functions (retrospectively and concurrently) as needed to ensure ongoing and timely workflow.

• Assists with compliance reviews for accuracy of coding and abstraction to include performance monitoring studies and evaluates quality of coding assignment and integrity of data to ensure the expected level of accuracy is maintained in the coding department.

• Provides positive feedback and constructive input to coding specialists regarding performance.

• Works with coding leadership to develop and implement action plans to maintain accuracy and productivity with the department.

• Monitors the Senior Coding assigned work queues in EPIC to ensure timely responses to coders within 24 hours.

• Serves as an additional resource regarding ICD-10 and CPT-4 coding assignment.

• Provides support to all coding specialists as needed to promote accurate, quality coding.

• Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training

• High school graduate or equivalent required

• Certified Coding Specialist (CCS) credential required

• Associate's degree in Health Information Management preferred

• RHIA/RHIT preferred

Work Experience

• 5 years ICD-10 and CPT-4 coding experience in a hospital setting required

• 3 years auditing experience and/or lead coder experience preferred

Knowledge, Skills, and Abilities Required

• Proficiency in reading, writing, and speaking the English language

• Knowledge of ICD-10-CM/PCS and CPT 4 coding

• Knowledge of anatomy and physiology, medical terminology and the various medical specialties as required to accurately code all different types of medical records

• Ability to effectively coordinate staff training and continuing education

• Ability to work well independently

• Ability to problem- solve

• Excellent written and oral communication skills.

• Knowledge of medical necessity guidelines and recognition of the impact on coding accuracy and appropriate hospital reimbursement

Physical Requirements

• Job requires computer literacy

• Speech, sight and hearing required as incumbent must work independently in effectively training and monitoring coding functions

• Long periods of sitting

Required Licenses and Certifications

CCS - American Health Information Management Association

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity