BASIC PURPOSE OF THE JOB

Under general supervision and according to established procedures, assigns diagnostic codes to medical record information. Codes charts under the ICD 9 CM and HCPCS System for ancillary and clinical outpatient records. Responsible for assuring all outpatient ancillary department, emergency room and clinic records are coded and abstracted in a timely and accurate manner.

REPORTS TO

• Director-Health Information Management

JOB REQUIREMENTS

Supervisory Responsibilities: No

Minimum Education: Associates

Degree: Health Information Management or related field

License/Certification Required: RHIT, RHIA and/or CCS preferred

Minimum Work Experience: 3 years inpatient and outpatient surgery coding experience preferred.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Knowledge of medical terminology, anatomy & physiology, and ICD-9-CM and CPT-4 coding guidelines.
• Excellent communication skills. Detail-oriented with organizational and time management skills.
• Proficient in computers, word processing and computer applications.
• Problem solving skills.
• Proficient in the use of reference materials and resources.

DUTIES AND RESPONSIBILITIES

• Analyzes patient emergency room medical records and interprets documentation to identify all diagnoses. Assigns proper ICD 9 CM diagnostic codes to charts and related records by reference to designated coding manuals and other reference material.
• Applies uniform hospital discharge data-set definitions to select the principal diagnosis, and other diagnoses, that require coding, as well as other data items required to maintain the hospital database.
• Applies sequencing guidelines to coded data according to official coding rules.
• Identifies any and all complications or comorbidities.
• Assesses the adequacy of medical record documentation to ensure that it supports the principal diagnosis, principal procedure, complications, and comorbid conditions assigned codes. Consults with the appropriate physician to clarify medical record information.
• Remains abreast of developments in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature, and so forth.
• Promotes effective working relations and works effectively as part of a department/unit team inter- and intradepartmentally to facilitate the department’s/unit’s ability to meet its goals and objectives.
• Demonstrates respect and regard for the dignity of all patients, families, visitors, and fellow employees to ensure a professional, responsible, and courteous environment.
• Continuously displays a positive attitude within the department and across departmental lines to contribute to the overall customer service program in place at hospital.
• Assists intradepartmental and external co-workers as needed in a courteous and professional manner.
• Willing accepts any other assignment that may be requested.
• Maintain the coding the inpatient, observation and same day surgery accounts within 4 day post discharge.
• Utilizes hospital resources and time respectfully and accountably.

PHYSICAL REQUIREMENTS

• Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
• Medium lifting, pushing and pulling is required for 20-50 lbs occasionally, 10-20 pounds frequently and 10 lbs constantly to move objects. Sudden emergency situations have the potential for exposure for lifting or moving of up to 100 lbs. Frequent bending, walking, sitting, squatting, reaching, and standing are required. Keyboard/computer use and/or repetitive motions may be required.

Come work where you can make a difference everyday.