Job Description

GENERAL SUMMARY:

Under the supervision of Supervisor of Coding, performs the following functions:

1. Identifies, reviews, interprets, codes, and abstracts clinical information from the inpatient, observation, 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.

 2. Consults with physicians and other departments regarding medical/surgical services, clinical procedures and clarification of discrepancies in documentation.

3. Meets coding and abstracting deadlines and productivity and quality standards to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care.

 4. Performs other duties as assigned.

MINIMUM QUALIFICATIONS:

Education, Knowledge, Skills and Abilities

• Certified Coding Specialist credential, or Associate=s degree (A.A.) in Health Information Technology from an accredited two-year college or technical school with RHIT credential, or Bachelor=s degree (B.A.) from a four-year college or university in Health Information Management with RHIA credential preferred. Working knowledge of human anatomy and physiology, disease processes, medical terminology, organization of the medical record and medical record coding systems.
• Demonstrated knowledge of accurate application of ICD-9-CM and CPT coding principles.
•  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.
•  Demonstrated knowledge of the use and operation of CRT/PC systems to retrieve computerized data, utilize PC-based encoding application, mainframe applications, etc.
•  Requires strong verbal and written communication skills.
• Must be detail oriented; possess ability to perform duties with minimum direct supervision; ability to organize and record information appropriately and resolve problems independently.
• Above knowledge normally attained through an Associate's Degree in Medical Record Technology (credentialed through OHIMA).

Required Length and Type of Experience

• One year experience in the application of ICD-9-CM and CPT-4 coding, recording of and interpreting clinical data from medical records.

Required Registry, Certification, or Licensure

• None Required

Required Physical and Environmental Demands

• Typical physical demands involve prolonged sitting and dexterity to accurately operate a data entry/PC keyboard.
•  Manual dexterity required to locate and lift medical charts.
•  Ability to work under stress and to meet imposed deadlines for research projects, etc.

 -HDS-

Benefits

Medical, Dental, Disability, Prescription, Vision, Life, Holidays, 403B, Retirement Plan, Flexible Spending, Paid Time Off, Tuition Reimbursement