Job Description

JOB SUMMARY: Under the supervision of the Supervisor of Coding, performs the following functions: Identifies, reviews, interprets, codes, and abstracts clinical information from the observations and in and out surgical records for the purpose of reimbursement, research, and compliance with federal regulations and other agencies utilizing established coding principles and protocols. Meets coding and abstracting deadlines to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care. Meets productivity and quality standards. Prepares records of registered appointments and in/out surgery patients for inclusion in the permanent medical record. Analyzes/ reanalyzes in/out surgery records for completeness and compliance with standards and policies. Performs data entry for Discharge Processing and reanalyzes as required. Logs records in and out of the department via the computerized chart tracking system. Responds to telephone requests for records, expedites from sorting, and checks from dictation listen line. Consults with physicians and other departments regarding medical/ surgical services, clinical procedures, and clarification of discrepancies in documentation. Performs other related duties as assigned. MINIMUM QUALIFICATIONS: Associate's degree (A.A.) in Health Information Technology/ Medical Record Terminology (ART) from an accredited two-year college or technical school; or two years experience in the application of ICD-9-CM and CPT-4 coding, recording or and interpreting clinical data from medical records. RRA with six months related coding experience may substitute for one and a half years coding experience. Ability to use PC/ CRT based encoding applications, mainframe applications with a high degree of accuracy to retrieve computerized data. Working knowledge of human anatomy and physiology, disease processes and medical terminology, organization of the medical record and medical record coding systems. Demonstrated knowledge of accurate application of ICD-9-CM coding principles. Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental regulations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public. Analytical ability sufficient to accurately abstract, code, and interpret data from diverse sources. Understanding of admission/ discharge/ transfer procedures and relationship to hospital/ physician billing systems. Requires strong verbal and written communication skills. Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Ability to solve practical problems and deal with a variety of concrete variable in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Must be detail-oriented; possess the ability to perform duties with minimum direct supervision; the ability to organize and record information appropriately and resolve problems independently. Ability to work under stress and to meet imposed deadlines for research projects, etc.. On-the-Job Training: After selection and placement into this position, at least four months of on-the-job training with attendance at comprehensive training sessions in order to code clinical data with a high degree of accuracy is required.Standing, walking, stooping, kneeling, crouching, crawling, talking and hearing less than one-third of the time. This position requires using hands to finger, handle, or feel and reaching with hands and arms two-thirds of the time. PC/CRT skills are required over two-thirds of the time. This position is required to lift or exert force between ten to twenty-five pounds. Close vision is required. This position is in a moderate noise level environment (business office with computers and printers). Typical physical demands involve prolonged sitting and dexterity to accurately operate a data entry/ PC/CRT keyboard. Manual dexterity required to locate and lift medical charts.

Benefits

Dental, Paid Time Off, Holidays, Flexible Spending, Medical, Life, Health Savings Account, 401K, Prescription