Job Description

GENERAL SUMMARY:

Under the supervision of the Manager, Business Development, a Coder I must identify, review, interpret, code and abstract clinical information from inpatient, observation, and in & out surgical records for the purpose of reimbursement, research and compliance with federal regulations and other agencies utilizing established coding principles and protocols.   A Coder I must meet coding and abstracting deadlines to expedite the RAC review process to ensure timeliness for requests.  Coder I will analyze findings and discusses discrepancies between documentation and code selection with the hospital coding department for clarification and educational purposes.  Coder I must meet productivity and quality standards as determined.  Maintains knowledge base by reviewing coding and reimbursement newsletters, attending in-service training sessions and participating in continuing education workshops.

MINIMUM QUALIFICATIONS:

Education, Knowledge, Skills and Abilities

• A Coder I must have an Associate's Degree in Health Information Technology or related field from an accredited two year college or technical school or a Bachelor's Degree from a four year college or University in Health Information Management or a related field or have a Certified Coding Specialist Credential.
• They must have the following:  In-depth knowledge of human anatomy and physiology, disease processes, medical terminology, organization of the medical record and medical record coding systems. 
• Understanding of admission /discharge/transfer procedures and relationship to hospital/physician billing systems.
•  Demonstrated knowledge of the use and operation of PC/CRT systems to retrieve computerized data, utilize PC-based encoding applications, mainframe applications, etc. 
• Ability to read, analyze, and interpret 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.  Requires strong verbal and written communication skills. 
• Must be detail oriented; possess the ability to perform duties with minimal direct supervision;  ability to organize and record information appropriately and resolve problems independently.
•  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 variables in situations where only limited standardization exists.
• Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Must be detailed oriented and able to organize and record information appropriately.
• After selection and placement into this position, at least three months of on-the-job training with attendance at comprehensive training sessions in order to code clinical data with a high degree of accuracy.
• Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA) preferred, or have a Certified Coding Specialist Credential.  
• PC/CRT skills are required over two-thirds of the time. 

 Required Length and Type of Experience

• A Coder I must have two or more years experience in the application of ICD-9-CM and CPT-4 coding, recording of and interpreting clinical data from medical records. 

Required Physical

• Physical demands include: 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 to retrieve charts two-thirds of the time.
• Close vision is required. 
• The position is required to lift or exert force between ten to twenty-five pounds. 
• The 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 keyboard. 
• 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