HIM Coder 2 - Outpatient

Position Overview

Under the general supervision of the Manager and direct supervision of the Supervisor, the Coder 2 at Tampa General Hospital is responsible for ensuring accurate medical record abstraction and coding. This role utilizes the encoder system to assign diagnosis and procedure codes, calculates the corresponding grouping values, and collaborates with various teams to clarify documentation. The position demands adherence to professional guidelines and quality standards while contributing to the overall mission, vision, and values of the hospital.

Key Responsibilities

• Perform a thorough review of medical record documentation to accurately assign diagnosis and procedure codes.
• Utilize the encoder system to sequence codes and calculate the corresponding MS-DRG/APR DRG/APC grouping.
• Abstract patient information into computerized medical record and billing systems, ensuring data integrity prior to finalizing the encounter.
• Collaborate with the Clinical Documentation Improvement Team, Coding Team Coordinators, and/or Supervisor to query for clarification of ambiguous documentation.
• Maintain quality and productivity standards for moderate to high-complexity inpatient and outpatient records.
• Provide guidance and assistance to Coder I staff, Apprentices, and clinical practice students as needed.

Required Qualifications

• High School Diploma or GED.
• Certified Coding Specialist (CCS) or RHIT (Registered Health Information Technician) certification through the American Health Information Management Association (AHIMA) or RHIA (Registered Health Information Administrator) certification through AHIMA.
• Two (2) years of coding experience in an acute care setting.