Clinical Coder IV/Acute Care

  • Carolinas Healthcare System
  • Charlotte, NC, USA
  • Apr 25, 2018
Full time

Job Description

Location Details:  Arrowpoint
Carolinas HealthCare System is Atrium Health. Our mission remains the same: to improve health, elevate hope and advance healing - for all. The name Atrium Health allows us to grow beyond our current walls and geographical borders to impact as many lives as possible and deliver solutions that help communities thrive. For more information, please visit
Job Summary
Reviews clinical documentation and diagnostic results as appropriate to extract abstract data and apply appropriate ICD-9-CM/ICD10-CM/PCS and CPT 4 codes for reimbursement and external reporting, research, regulatory compliance, medical necessity, CCI, NCCI and any other regulatory edits. Code and abstract medical records of high complexity within the CHS Primary Enterprise acute care facilities.

Essential Functions
  • Reviews medical records of high complexity to identify the appropriate principal diagnosis and procedure codes, all other appropriate secondary diagnoses and procedure codes. Assign and present on Admission, Hospital Acquired Condition and Core Measure Indicators for all diagnosis codes.
  • Facilitates appropriate MS-DRG for inpatient medical records and appropriate APC assignment for outpatient medical records using UHDDS and other facility guidelines.
  • 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.
  • Reviews charges and Evaluation and Management levels.
  • Demonstrates proficiency with Microsoft Office Applications and in using required computer systems with minimal assistance.
  • Abstracts coded data and other pertinent fields in the hospital electronic health record.
  • Ensures the accuracy of data input.
  • Meets established quality and productivity standards.
  • Facilitates peer review and training for all Acute Clinical Coders in the coding department. Provides support to management.
  • Stay abreast of coding principles and regulatory guidelines related to inpatient and/or outpatient coding.
Physical Requirements
Must be able to concentrate and sit for long periods of time while reviewing electronic health records. Daily and weekly deadlines must be met in a fast paced office environment and/or at home environment.

Education, Experience and Certifications.
High school diploma or GED required; Bachelors degree preferred. Advanced knowledge in Medical Terminology, Anatomy and Physiology and Pharmacology required. 4 years coding experience in acute care setting required. Current RHIA, RHIT, CCS, CPC-H, CPC or CIC required plus a passing score on the CHS Coding test. 
At 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.
Posting Notes: Not Applicable
Carolinas HealthCare System is an EOE/AA Employer