POSITION DESCRIPTION/ COLUMBUS REGIONAL HEALTHCARE SYSTEM HEALTH INFORMATION MANAGEMENT

Transcription

1 POSITION DESCRIPTION/ COLUMBUS REGIONAL HEALTHCARE SYSTEM JOB TITLE CODING SUPERVISOR JOB CODE 0172 DEPARTMENT FLSA (Exempt/Non-Exempt) HEALTH INFORMATION MANAGEMENT NON-EXEMPT DEPARTMENT DIRECTOR SIGNATURE ADMINISTRATIVE DIRECTOR SIGNATURE V. P. HUMAN RESOURCES SIGNATURE EFFECTIVE DATE 01/28/09 REVISION DATE 04/02/15 DESCRIPTION SUMMARY: Organizes and supervises the operations and human resources for the coding functions of the department. EDUCATION, CREDENTIALS AND TRAINING: Required: Two-year degree in Health Information Management, Healthcare Administration or Associate degree in Nursing Expert knowledge of coding procedures and rules. Proficient in use of keyboard, dictating equipment and standard office equipment. Preferred: Registered Health Information Technician certification. Certified Coding Specialist. Supervisory training and development. EXPERIENCE: One year of medical records experience or nursing experience and coding knowledge in a hospital environment required. Demonstrated supervisory potential. Given training and on-the-job experience incumbent should be proficient in the basic aspects of the job within three months. OTHER: Verbal communication skills. Interpersonal skills. Organizational skills. Problem solving and decision making skills. Leadership skills. ORGANIZATIONAL RELATIONSHIPS: Supervises: Coding Personnel Reports To: Director, Health Information Management COMMUNICATIONS: Requires frequent communications with departmental personnel, physicians, nursing and other hospital personnel providing services that interface with Health Information Management. Periodic communications with vendor service representatives, auditors, attorneys and law enforcement personnel. Purpose includes giving and receiving information, explaining services, rules or procedures, or providing instructions or directives regarding policies or standards. Requires well-developed communication skills to obtain cooperation and understanding, discuss and resolve problems, make recommendations and maintain goodwill.

2 WORKING HOURS AND OVERTIME STATUS: Normally works 8:30am-5:00pm, Monday-Friday. May be required to work alternate schedules or additional hours as the workload demands. Classified as non-exempt for purposes of overtime. DRESS POLICY: Business attire. WORKING ENVIRONMENT: Spends almost all of the time in light and temperature controlled office environment. EXPOSURE DETERMINATION: OSHA requires an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. The exposure determination is made without regard to the use of personal protective equipment (i.e. employees are considered to be exposed even if they wear personal protective equipment.) This exposure determination is required to list all job classifications in which all employees may be expected to incur such occupational exposure, regardless of frequency. It is the department s responsibility to perform exposure determination for all employees and to list job classifications in one of three categories. Category 1 includes employees who are routinely exposed to blood borne pathogens Category 2 includes employees who are not usually exposed, but for whom contact with infectious materials can be reasonably anticipated during the course of their duties. Category 3 is for employees who are not exposed to infectious materials during the normal operations of their job duties. This job is rated as a category 3 (1, 2, or 3). BIOHAZARDOUS DRUGS: As a health care facility which dispenses drugs, some of which have been identified as hazardous by NIOSH, our goal is to provide training and where necessary, personal protective equipment (PPE) to insure employee safety. *See list of hazardous drugs in Oncology Policies, Chemotherapy Preparation section. Warning labels will be used to identify drugs requiring special handling or waste disposal procedures. It is the department s responsibility to train in safe handling and disposal. It is the employee s responsibility to follow policies and procedures, and to report situations and/or make recommendations to improve safety. It is also the department s responsibility to perform exposure determination for all employees and to list job classifications in one of three categories. Category 1 includes employees who are routinely exposed to hazardous drugs. Category 2 includes employees who are not usually exposed, but for whom contact with hazardous drugs can be reasonably anticipated during the course of their duties. Category 3 is for employees who are not exposed to hazardous drugs during the normal operations of their job duties. This job is rated as a category 3 (1, 2, or 3). WORK AIDS: Computer terminal and printer. Copier. FAX machine. Telephone. Administrative supplies. Patient medical records. Reference books. Employee records. Administrative records, reports and manuals.

3 KEY ELEMENTS: CLINICAL DATA COORDINATOR Ensure accuracy of coding in 97-98% randomly selected charts for conditions to include any complications or co-morbidities with any principle associated procedures. Effectively organize, prioritize and intervene as necessary in coding and abstracting functions so that designated time frames and/or production standards are met overall, on average, over the course of the year. Audit coding functions by outside vendors in accordance with procedure or instructions, as evidenced in 96% of 24 random audits, and no more than 2-3 otherwise noted exceptions per year. Maintains a production rate that meets current standards as set by department Director for inpatient, ER, REF/RCR coding and abstracting. JOB ACCOUNTABILITIES 1. Direct selected administrative operations pertaining to coding functions under the general direction of the department Director. -Take responsibility for ensuring that designated Joint Commission and other regulatory/legal requirements are met -Evaluate new products, services and equipment for applicability and feasibility -Monitor productivity of coding areas a. Ensure that designated Joint Commission and other regulatory requirements are met, to include documentation, on an on-going basis. b. Establish methods to monitor coding services to ensure appropriateness, consistency, compliance and understanding of procedures, practices and associated changes. c. Monitors productivity of coding areas as needed. 2. Direct assigned personnel, under the general supervision of the department Director. -Interview applicants and make hiring recommendations in conjunction with the Director -Orient new employees to the general hospital and departmental policies and procedures, with the knowledge and approval of the Director -Train new employees in the specifics of jobs, and provide in-services to existing staff when new or revised policies and procedures are implemented -Provide for on-going continuing education opportunities and professional growth opportunities for staff, with the knowledge and approval of the Director -Keep employees informed of hospital and departmental activities, announcements and changes that affect them through daily communications -Make work assignments, with the knowledge and approval of the Director -Check work methods and work results for quality, accuracy and timeliness a. Ensure that applicants recommended for hire meet minimum requirements for the position as outlined in the job description. b. Provide for the orientation and on-going training of assigned personnel to departmental policies and procedures, ensuring that documentation systems are established and maintained, so that status, progress and participation can be easily monitored. c. Routinely provide for "on-the-spot" in-services for assigned staff when minor deficiencies are observed, so that problems do not persist or grow worse. d. Establish and implement effective in-service training sessions for all staff to address new/revised policies, procedures, and advances in products

4 and techniques. e. Contribute to the professional development of assigned personnel, by observing work, tracking performance indicators, answering questions, explaining proper procedures, demonstrating techniques, and intervening as warranted to correct deficiencies or help resolve problems. f. Continuously assess performance of assigned personnel, documenting significant achievements and/or deficiencies, and coaching or counseling, as appropriate, to maximize employee capabilities and performance. g. Ensure that assigned personnel comply with hospital and departmental policies, providing timely notification, interpretation and instruction, and as appropriate, recommending and applying disciplinary action. h. Ensure the quality and timeliness of services provided by assigned personnel, intervening as appropriate to resolve problems or correct deficiencies. i. Prepare a timely and substantiated performance review for each assigned employee in accordance with procedure, ensuring that action plans are made to improve performance weaknesses, that plans are made for future activities and for personal development, and that ratings are properly substantiated by performance notes taken throughout the course of the review period. j. Effectively resolve staffing problems due to absences or fluctuations in workload, so that significant delays in service do not occur. k. Keep assigned personnel fully informed on assignments or personnel matters that affect them. l. Complies with employment-related laws and policies, with no adverse outcomes (litigation, sanctions or fines) for the hospital. 3. Collaborate on, and coordinate work with physicians, departmental personnel, other hospital personnel and outside resources. a. Provide clear, relevant and accurate communications with respect to documentation, medical records actions, issues and concerns. b. Effectively collaborate with others, as warranted, ensuring that communications are professional, clear and timely. c. Coordinate information management related to coding. 4. Participate in departmental quality assurance and quality improvement activities. a. Effectively perform data collection, analysis and idea generation pertinent to coding quality assurance and quality improvement programs, on an on-going basis, without prompting. 5. Monitors all activities related to coding and abstracting functions, and perform associated functions. -Track and expedite action on accounts receivable related to uncoded accounts a. Ensure that accounts not billed due to missing or insufficient information are identified and resolved with the appropriate physician, in the shortest possible time frame. b. Effectively investigate and resolve any problems with third party reimbursement that are attributable to coding issues. c. Effectively communicate with physicians when obtaining or clarifying information, so that goodwill and cooperation are maintained. d. Clinical abstracts are accomplished in accordance with procedure and time frames. e. Keep assigned work area in a neat and orderly condition on an on-going basis.

5 6. Perform final coding verifications on all patient visits and assigns DRG. a. Properly apply standard definitions to select the principle Dx, any secondary conditions to include any complications or co-morbidities, and any principle associated procedures, when coding medical records. b. Accurately enter codes into computer so that appropriate DRG/APC is determined. 7. Follow the Standards of American Health Information Management Association Ethical Coding. a. Diagnoses that are present on admission or diagnoses and procedures that occur during the current encounter are to be abstracted after a thorough review of the entire medical record. Those diagnoses that are not applicable to the current encounter should not be abstracted. b. Oversees the correct selection of the principal diagnosis and principle procedure, along with other diagnosis and procedures, must meet the definitions of the Uniform Hospital Discharge Data Set. c. Assessment must be made of the documentation in the chart to ensure that it is adequate and appropriate to support the diagnoses and procedures selected to be abstracted. d. Ensures medical record coders should use their skills, their knowledge of ICD-9-CM/ICD-10CM and CPT, and any available resources to select diagnostic and procedural codes. e. Ensures that medical record coders do not change codes or narratives of codes so that the meanings are misrepresented. Nor should diagnoses or procedures be included or excluded because the payment will be affected. Statistical clinical data is an important result of coding, and maintaining a quality database should be a conscientious goal. f. Ensures Physicians are queried or consulted for clarification when they enter conflicting or ambiguous documentation in the chart. g. This position is a member of the healthcare team and, as such, should assist physicians who are unfamiliar with ICD-9-CM/ICD-10CM, CPT, or DRG methodology by suggesting re-sequencing or inclusion of diagnoses or procedures when needed to more accurately reflect the occurrence of events during the encounter. h. Ensure the medical record coder is striving for the optimal payment to which the facility is legally entitled, but it is unethical and illegal to maximize payment by means that contradict regulatory guidelines. 8. Perform miscellaneous duties, as needed. -Oversees department activities in the absence of the Director -Update charts in the incomplete system -Perform duties of other medical records personnel as needed -Perform other duties as assigned a. Accomplish routine and non-routine miscellaneous assignments in accordance with procedure or instructions, and time frames.