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Senior Outpatient Coder

Job Ref: 27403

Talent Area: HIM/Medical Records

Houston Methodist St. Catherine
Katy, TX 77450

Area/Department: Med Records-Corporate Coding

Employment Type: Regular

Job Type: Full-Time

Organization: Houston Methodist

Work Shift: DAY

Work Week: M - F

Company Profile

Houston Methodist St. Catherine Hospital is the first specialty hospital in the Houston Methodist family. Located in the heart of the Katy community, the facility provides a special menu of services for both inpatient and outpatient care by team members called to serve with excellence and compassion:

  • Specialized inpatient care for those patients requiring a longer hospital stay
  • Outpatient physical and speech therapy
  • State-of-the-art diagnostic imaging such as X-ray, MRI, CT
  • Women’s Center with advanced mammography

Job Summary

This position exists to ensure diagnostic and procedure codes are assigned accurately to day surgery and observation encounters based upon documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines.
Select the applicable age group(s) of primary customers/patients served by this position.

 Not applicable
 Neonate (Birth to 28 days)
 Infants/Toddlers (29 days to 18 months)
 Toddler (18 months to 3 years)
 Preschooler (3-6 years)
 School Age (6-12 years)
 Adolescence (12-18 years)
 Young Adult (19-40 Years)
 Middle Adult (40-65 Years)
 Mature Adult (65 years and older)


I. Provide personalized care and service by consistently demonstrating our I CARE values:

INTEGRITY: We are honest and ethical in all we say and do.
COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
ACCOUNTABILITY: We hold ourselves accountable for all our actions.
RESPECT: We treat every individual as a person of worth, dignity, and value.
EXCELLENCE: We strive to be the best at what we do and a model for others to emulate. 

II. Focuses on patient/customer safety
III. Delivers personalized service using HM Service Standards
IV. Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)
V. Intentionally rounds with patients/customers to ensure their needs are being met
VI. Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

Duties and Responsibilities are cross-referenced to Houston Methodist¿s Pillars of Excellence and will be transferred to the Performance Evaluation.

PEOPLE (20%)
1. Interacts and communicates effectively with members of the coding team and HIM, physicians, IT, Patient Access and Business Office. (EF)
2. Participates and provides good feedback during coding section meetings and coding education inservices. (EF)
3. Takes initiative to assist others and shares knowledge with the coding group, business office, physicians and nurses on official coding guidelines. (EF)

1. Responds promptly to internal and external customer requests. Responds promptly to Business Office requests to code or review coded accounts for accuracy. (EF)
2. Strives to exceed coworkers' expectations. Provides assistance to the team lead or other coders with coding of the accounts or answering questions from other coders relating to coding and work flows. (EF)
3. Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process. (EF)

1. Maintains and achieves the highest standards of coding quality by assigning accurate ICD-9-CM/ICD-10-CM/ICD-10-PCS and CPT codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines. (EF)
2. Performs accurate, optimal APC assignment, in accordance with nationally established rules and guidelines based upon documentation within the medical record. (EF)
3. Reviews discharge disposition entered by nursing and corrects if necessary in order to achieve the highest quality of entered data. (EF)
4. Assigns and enters physician identification number and procedure date correctly in the medical record abstracting system. (EF)
5. Reviews medical record documentation and abstracts data into the encoder and Hospital Information System (HIS)/Electronic Health Record (EHR) abstracting system to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions and procedures. (EF)
6. Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official guidelines.
7. Maintains 95% accuracy in coding and abstracting. (EF)

1. Utilizes time effectively. Consistently codes and abstracts at minimum productivity standards while ensuring accuracy of coding. (EF)
2. Assists in making sure coding bill hold goal is met by working additional hours as authorized. (EF)
3. Maintains coding timeframes within acceptable guidelines by ensuring all work items assigned to the coding queues and Aeos worklists are processed in a timely manner. (EF)
4. Ensures work flows and worklists are reviewed or monitored in order to identify old uncoded accounts or problem accounts. (EF)

1. Demonstrates adaptability and flexibility in the face of changing demands. Shows willingness to perform additional tasks as assigned. (EF)
2. Accepts feedback and changes behavior appropriately. (EF)
3. Displays initiative to improve relative to job function. Contributes ideas to help improve quality of coding data and abstracting data. (EF)

This job description is not intended to be all inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

1. Associate degree in a CAHIIM accredited program and 3 to 5 year relevant outpatient coding experience or successful completion of the Houston Methodist Senior Outpatient Coder Transition Program,
2. Bachelors degree in a CAHIIM accredited program and 3 to 5 year relevant outpatient coding experience or successful completion of the Houston Methodist Senior Outpatient Coder Transition Program,
3. CCS and 5 years relevant outpatient coding experience or successful completion of the Houston Methodist Senior Outpatient Coder Transition Program.

Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist (CCS)

Please add additional knowledge, skills and abilities required to perform the essential functions.

 Knowledge of coding classification systems, DRG and APC systems, official coding guidelines and coding compliance, required
 Knowledge of an electronic medical record and imaging systems, preferred
 Working knowledge of medical terminology, anatomy and physiology, required
 Proficiency with electronic encoder application, preferred
 Must be able to type 40 words per minute with extensive PC knowledge
 Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security.
 Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles.

Activity Checklist attached (see below)

Normal office conditions

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of  race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law.

VEVRAA Federal Contractor – priority referral Protected Veterans requested.