Clinics Coder - Medical Records (Full Time)

JOB SUMMARY

Accountable for conversion of diagnoses and treatment procedures into codes using an international classification of diseases. Sequencing of diagnoses/procedures to optimize reimbursement.

Ensures patient records are coded in an accurate and timely manner. Reports to HIM Director. Non-Exempt position.

ESSENTIAL FUNCTIONS

Ensures that records are coded within 4 days of date of service, excluding weekends and holidays.

Reviews chart thoroughly to ascertain all diagnoses/procedures and charges.

Contacts responsible physician in a professional, tactful manner, if diagnosis or documentation is not available on chart.

Refers chart to director, if there is a question regarding the diagnoses/codes.

Utilizes computerized coding/abstracting equipment.

Codes all diagnoses/procedures in accordance to ICD-10-CM and CPT-4 coding principles and the Coding Manual.

Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded.

Notifies director whenever work is more than 48 hours behind work deadline.

Acts as a resource person to clinic staff for coding and may provide education regarding coding changes/issues.

Codes all diagnosis/procedures in accordance to ICD-9/10-CM/CPT coding principles.

Ensures physician/hospital compliance with all state and federal billing regulations and reports suspected compliance issues to management.

Ensures that records are coded within 4 days of service, excluding weekends and holidays

Works with supervision, management and the physician staff to improve processes, increase accuracy, create efficiencies and achieve the overall goals of the department.

Performs other duties as assigned.

POSITION REQUIREMENTS

Minimum Education

High School Diploma or GED required.

One year previous clinic experience in outpatient coding (or related position) required.

Certified Coder Associate (CCA), Certified Professional Coder (CPC), Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA), or Certified Coding Specialist-Physician (CCS-P) certification preferred.

Required Skills

Must possess superior ability to communicate effectively in English, both verbally and in writing. Additional languages preferred.

Excellent interpersonal skills and customer service.

Must possess high degree of organization and be able to multi-task efficiently and effectively.

Advanced computer knowledge required, including proficiency in Microsoft Office and Outlook.

FUNCTIONAL DEMANDS

Functional Job Requirements:

Job requirements include, but are not limited to: sitting, standing, walking, kneeling, bending, squatting and reaching. Requires good finger dexterity, repetitive motions with hands and fingers.

Requires ability to have good vision and hearing. Pushing and pulling equipment may be necessary.

Lifting Requirements

Job requires medium lifting on an occasional basis.

Reasonable Accommodations

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising the job duties.