• Assigns accurate ICD diagnosis codes, using compliant documentation. • Assigns accurate CPT/HCPCS codes to records, using compliant documentation. • Applies knowledge of Coding Guidelines to select the appropriate diagnosis code. • Uses available research and reference tools to understand the disease process and diagnosis. • Interprets physician documentation within the coding guidelines and obtains clarification from physicians regarding vague or ambiguous record documentation. • Enhances coding knowledge and skills with continuing education activities as described in HIM.COD.003 policy and by reviewing pertinent literature.

Role Description Baptist Medical Center Jacksonville is currently hiring for a Full-time Team Lead to join our Inpatient Coding team. This candidate will assist the Manager/Supervisor in coordinating daily operations ensuring accurate, compliant, and timely coding of Inpatient records to optimize revenue. They will also be responsible for orientation and training of new staff. This is a remote position. Inpatient Coder Team Lead Responsibilities include: - Responsible for correctly identifying and assigning diagnosis and procedure codes using the ICD-10-CM/PCS Classification System to each patient's record for optimization in accordance with State and Federal requirements on Inpatient accounts. - Be knowledgeable of CPT codes, edit resolution and assigning CPT-4 Codes on Observation accounts when applicable. - Verifies and submits abstracted UB04 information across the billing system for claim submission. - Must efficiently complete this activity for 100% of patient's discharged records daily to maintain the Coding A/R goals set forth. - Works ACHA, DNFB and Post Bill error reports, such as A/B rebills, Claim Edits, and Denials when applicable. - Advises and coordinates with Management, CDI and HIM on coding documentation. - Provides support to Coders, CDI and other staff via mentorship, and possesses auditing and training skills. - Requires critical thinking skills, effective communication skills, decisive judgement and the ability to work with minimal supervision. - Must be focused and detail oriented and have effective time management skills. - Proficient in basic computer skills and able to utilize a computerized encoder and EHR. Qualifications - High School Diploma - Bachelor of Science (non Nursing) preferred - Associate of Science preferred - Certified Coding Specialist - AHIMA - Registered Health Information Technician (RHIT) - AHIMA - Certified Coding Specialist - AHIMA Requirements - 3-5 Years Experience working in an Acute Care setting - Knowledge base in Coding Clinic Guidelines - Knowledge base in Physiology - Knowledge base in Anatomy - Candidate must reside in the following approved states: Alabama, Florida, Georgia, Idaho, Indiana, Kentucky, Louisiana, Mississippi, North Carolina, Ohio, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Virginia, West Virginia, Wyoming. Company Description Recognized as a top place to work in health care, Baptist Health cares for more patients in Northeast Florida than any other provider, ranking as “most preferred” for more than 30 years. We’re Jacksonville's only locally governed, faith-based, not-for-profit health system and provide a full spectrum of preventive and specialty care through 200+ locations and six hospitals. Our centers of excellence include Baptist MD Anderson Cancer Center, Baptist Heart Hospital, Baptist Neurological Institute and Wolfson Children's Hospital. For more than 25 years, health care consumers have named Baptist Health the "most preferred healthcare provider" in the region. At Baptist Health, we are proud to be local, providing multigenerational care to our community. We are the hospital Jacksonville trusts the most. Our employees can take pride in their Baptist Badge, knowing the impact they make on their friends, family, and neighbors. Baptist was recently recognized by Forbes magazine as one of America’s top employers for diversity.

Role Description The Health Information Coder III, Per Diem is a senior-level inpatient coder with the knowledge and skill set to utilize the ICD-10-CM and ICD-10-PCS classification systems to code acute academic, teaching inpatient cases. The skill set extends to knowledge and comprehension of code sequences into Diagnoses-Related Groups on acute academic, teaching inpatient cases. Cases are coded to comply with the official guidelines for coding and reporting, practice standards and code of ethics for HIMS coder. Cases are abstracted according to UCSF Health policies and procedures. The focus of coding and abstracting is on a range of all primary hospital services. There is minimal review of coding for quality. Duties and Essential Job Functions - Retrieve and analyze comprehensive medical records and information systems for appropriate documentation and follow-up as appropriate. - Evaluate full episode of care of clinical data for inpatient cases and assign appropriate codes using ICD-10-CM and ICD-10-PCS classification systems. - Includes assessment of the condition and diagnosis to conclude the coding of clinical data and DRG assignment. - Meet external requirements for HCAI, HCFA, The Joint Commission, NCQA and payor data requirements. - Accurately input codes and abstract data into current coding databases. - Participate in coding audits and coding educational sessions and provide feedback and training. - Meet or exceed department production standards for the DRG coding level. - Meet or exceed department quality standards for the DRG coding level. - Maintain knowledge of current medical terminology, disease processes, anatomy & physiology, and current DRG coding guidelines. - Follow-up and clarify physician documentation (dictation and clinical notes). - Report to a lead or manager. - Interact with internal and external UCSF Health staff and customers. - Satisfactory time and attendance. Other Functions and Responsibilities - Demonstrate understanding of DRG coding mission within UCSF Health. - Demonstrate understanding of DRG coding, AR, and data submission information flow. - Ability to solve problems and troubleshoot computer issues. - Perform data searches. - Maintain patient confidentiality and IT security. - Treat others with respect and work well on a team. - As requested, train others. - Follow safety and infection control guidelines. - Maintain equipment and work area. - Comply with the UCSF Health dress code. - Other duties as assigned.

Role Description Under supervision by the Trauma Program Manager, the Trauma Registrar is responsible for the detailed review, abstraction and input of patient information into the trauma and burn registry databases. - Concurrently and retrospectively collects data from patient electronic health records and various computer-generated sources on all trauma and burn patients admitted or referred to Hennepin Healthcare HCMC and/or with a Trauma Team Activation. - Gathers accurate information to process records and determines trauma or burn patient eligibility inclusion criteria, accurately entering data into the trauma and/or burn registries. - Encodes the data, including ICD-10 coding, trauma registry coding, abbreviated injury scoring (AIS), injury severity scoring (ISS), National Trauma Data Standards (NTDS) Data Dictionary, American Burn Association (ABA) Data Dictionary, and MNTrauma Data Dictionary, using pre-established guidelines. - Maintains record keeping such as weekly time studies, tracking progression of completed and uncompleted cases, and continuing education credits. - Ensures accurate data entry of all injuries, procedures, complications, and required data fields as established by the NTDS, ABA, and MNTrauma data dictionaries, and HHS-HCMC specific trauma registry data elements. - Maintains code files and data dictionary. - Actively participates in data validation processes for accuracy and consistency of abstracting. - Participates in TQIP webinars, monthly education experiences, regularly scheduled registrar meetings, and Trauma Services huddles and staff meetings. - Attends Minnesota Trauma Registry Alliance (MTRA) meetings as appropriate. - Assists with preparation for trauma and burn center verification site visits. - Assists with quality projects and research activities as directed. - Performs additional responsibilities related to the Trauma Registry as assigned by the Lead Trauma Registrar, Trauma Program Manager, Trauma Medical Director, Trauma Data Analyst, Trauma PIPS Coordinators, Pediatric Trauma Coordinator, or Burn Program Coordinator. Qualifications - Completion of an Associate’s Degree or Bachelor’s Degree in Health Information Management -OR- An approved equivalent combination of education and work experience that includes: - 2-3 years of experience with medical terminology, anatomy, coding, data abstraction, and data management. - Experience and working knowledge of the ICD-10 coding classification system, with the ability to search for all appropriate codes using the index. - Successful completion of the following courses within 6 months of employment (if not done previously): - ATS Trauma Registrar Course - Trauma ICD-10 Diagnosis and Procedure Coding Course - AAAM Injury Severity Scoring Course Requirements - RHIT (Registered Health Information Technician) or RHIA (Registered Health Information Administrator) preferred. - Certified Abbreviated Injury Scale Specialist (CAISS) preferred. - Certified Specialist in Trauma Registry (CSTR) preferred. - Trauma Registrar experience at a Level I or II Trauma Center preferred. - Burn Registrar experience at a verified Burn Center preferred. - Successful completion of the ATS Trauma Registrar Course preferred. - Successful completion of a Trauma ICD-10 Diagnosis and Procedure Coding Course preferred. - Successful completion of AAAM Injury Severity Scoring Course preferred. - Working knowledge of ESO TraumaBase, ESO Burn Registry, or BData/BCQP burn registry databases preferred. Knowledge/Skills/Abilities - Computer skills with proficiency in Microsoft programs and EMR software. - Abide by strict confidentiality regulations as defined by HIPAA and hospital policy. - Ability to research information. - Critical thinking and problem-solving skills.