Summary: Codes diseases and operations for all Inpatient, Outpatient surgery, Observation, and Emergency Department discharges according to ICD-9-CM coding principals to provide uniform coding for the facility. Abstracts all Inpatient records into the STAR Abstracting system. Determines codes and sequencing for each diagnosis. Selects the best DRG possible by using the 3M Encoder and other appropriate resources to aid in the selection of principal diagnosis/procedure and complication/comorbid conditions. Effectively communicates with the Medical Staff if a question arises about the selection of a diagnosis/procedure on the medical record. Prepares, proofreads, and presents statistical reports as requested. Retrieves and organizes data, and aids in completion of both departmental and hospital quality assurance studies as assigned. Assists with coordination and maintenance of correspondence from PRO and other regulatory agencies. Participates in J.A. Thomas Review for better documentation practices and attends task force meetings. Perform DRG Review when in lead role. Maintains confidentiality and security of patient data stored in the medical record and electronic data systems. Performs duties and responsibilities in a confidential manner consistent with our mission and values.
Principle Accountabilities: % Of Time Spent
1.Codes diseases on Inpatient, Outpatient surgery, Observation, and Emergency Department discharges and enters information into the STAR Abstracting system on all Inpatient records (90%) 2.Effectively communicates with Medical Staff regarding any questions arising in regard to principal diagnosis/procedure (including participation in J.A. Thomas Review and task force meetings) (4%)
3.Prepares. proofreads, and presents statistical reports as needed (2%)
4.Retrieves, organizes, and aids in completion of both departmental and hospital quality assurance studies as assigned. (2%) 5.Assists with coordination and maintenance of correspondence from PRO and other regulatory agencies (1%)
6. Performs other work duties as assigned (1%)
Total: 100% SLH
Medical terminology, ICD-9-CM Coding expertise as well as computer key boarding skills required. Must possess good communication skills. Previous experience in a medical field preferred.
Associate or Bachelors degrees in health or science related field. Preferred Certification as ART or RRA.
Mission: Faithful to our Episcopal-Presbyterian heritage and its ministry of healing, St. Luke’s Hospital is dedicated to improving the health of the community. Using talents and resources responsibly, our medical staff, employees and volunteers provide care for the whole person with compassion, professional excellence, and respect for each other and those we serve.
Core Values: Human Dignity, Compassion, Justice, Excellence, and Stewardship.
Human Dignity: We accept and treat all persons as being created in the image of God.
Compassion: We respond with caring to the needs of others as if they were members of our family.
Justice: We honor each person’s rights and responsibilities in light of the common good.
Excellence: We set and strive to attain high standards of performance and continuous improvement.
Stewardship: We use our talents and resources wisely, with honesty and integrity.
FACES – Friendly – Available – Caring – Efficient – Safe
Communication Standards: Promotes and provides courteous and effective communication with internal and external customers.
At St. Luke's, each and every day, we put into practice our values:
We accept and treat all persons as being created in...