Lead Clinical Quality Coder/Auditor
At Atrium Health, formerly Carolinas HealthCare System, our patients, communities, and teammates are at the center of everything we do. Our commitment to diversity and inclusion allows us to deliver care that is superior in quality and compassion across our network of more than 900 care locations.
As a leading, innovative health system, we promote an environment where differences are valued and integrated into our workforce. Our culture of inclusion and cultural competence allows us to achieve our goals and deliver the best possible experience to patients and the communities we serve.
Remotely support World Class Service Lines, and with Documentation Excellence (DE) as the primary objective, the Lead Clinical Quality Coder/Auditor performs coding audits, shares results with physicians, physician leaders, and HIM/DE leadership, and trains new Clinical Coders. Reviews clinical documentation and diagnostic results as appropriate to extract data and apply appropriate codes for billing, internal and external reporting, research and regulatory compliance.
• Trains and orients new team members according to CHS specific guidelines while utilizing the facility encoder, HBOC and EMR.
• Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in an on-site or remote setting.
• Demonstrates proficiency with Microsoft Office Applications in using required computer systems with minimal assistance.
• Assists Coding leadership with continuing education for all coding personnel.
• Facilitates peer review and training for Coding personnel.
• Prepares and performs coding audits to ensure consistent, high quality coding, MS-DRG, APC, Present on Admission, Patient Safety Indicators, Hospital Acquired Conditions and Core Measures.
• Resolves error reports associated with billing process, identifies and reports error patterns, and, when necessary, assists in design and implementation of workflow changes to reduce billing errors.
• Assists with rebilling accounts when necessary.
• Coordinates flow of information between coding and other departments, which include Medical Records, Medical Audit, Patient Accounts, Performance Improvement, Corporate Compliance, RAC, DA2, Clinical Care Management, and other coding reviews as requested.
• Reviews inpatient and/or outpatient medical records to identify the appropriate principal diagnosis and procedure codes, all other appropriate secondary diagnoses and procedure codes and POA indicator for all diagnosis codes.
• High School Diploma or GED required; Bachelor’s Degree preferred.
• Advanced knowledge in Medical Terminology, Anatomy and Physiology, and Pharmacology.
• 5 years acute care facility coding and/or supervision required.
• Ability to work effectively as a trainer/educator while communicating effectively and patiently.
• Previous auditing and training experience preferred.
• Current RHIA, RHIT, CPC, CPC-H, CIC, or CCS required plus a passing score on the Atrium Health Coding test.