Department: Patient Accounts Services
Status: Full Time
Hours: Day Shift
The primary function of this position is to code and abstract all medical records using ICD-9/10 and CPT-4 guidelines to ensure accurate and ethical coding for reimbursement and statistical purposes.
indexing, reimbursement, research, and compliance with state/federal and hospital regulations.
- Daily assigns ICD-9/10 and CPT-4 codes to hospital records (IP, SNF, STO, SDS, ER, OUT) for the purpose of
- Maintain confidentiality of all information in accordance with HIPAA policies and procedures.
- Assists in organizing and planning the medical record section according to policies.
- Establishes proficiency with coding software, assigning DRG based on correct codes.
- Reviews computer data to ensure correct data entry.
- Obtains completed documentation from physicians as needed.
- Assists others in department by retrieving records and helping with incoming dept. phone calls.
- Adheres to all departmental and hospital policies and procedures.
- Attends seminars as assigned to ensure skills and knowledge are current in the coding field.
- Other duties as assigned.
- Assigns the proper ICD-9/10 and CPT-4 codes with 95% accuracy or above.
- Meets productivity guidelines as set forth in appropriate discipline:
- Inpatient & Skilled Nursing coding 2.5-3.5 charts per hour, includes abstracting.
- Short term Observation and Same Day Surgery coding 8-10 charts per hour, includes abstracting.
- Outpatient Ancillary coding 35-40 charts per hour.
- Emergency Department coding 9-12 charts per hour
- Correctly enters information into abstract with 95% accuracy or above.
Must be able to read, write, speak, and understand the English language. Must be high school graduate or have related GED. Prefer RHIT or CCS, but not required. Should be a formal coder training program graduate, or have completed an academic class in medical coding and/or have two years or directly related work experience. Should possess a working knowledge of medical record terminology, anatomy, physiology, and pharmacology. Must be able to operate efficiently a variety of the usual office equipment.
Should possess the ability to deal tactfully and work harmoniously with co-workers, patients, visitors, and the general public. Should also possess excellent verbal and written communication, good phone and interpersonal skills. Must be dependable and independent worker with good problem solving skills. Should also work well in a team atmosphere, assisting co-workers as needed. Must have customer service skills of patience, tactfulness, and friendliness when dealing with others. Must be able to multi-task and remain calm in chaotic situations.
This position is subject to long periods of standing, stooping, sitting, and bending. Position also subject to mental and emotional stressors, and must be able to see or hear, or use prosthetics that will enable these functions to operate. Must be able to deal with ill, disabled, elderly, emotionally upset, and sometimes hostile individuals. Subject to stressors related to computer keyboarding/viewing, including repetitive motions. Should be able to push, pull, move, and/or lift a minimum of 30 lbs, if needed.Application for Employment