Coder

POSITION TITLE: Coder

REPORTS TO (TITLE): Director of Health Information Management

DESCRIPTION OF POSITION:

Organizes and manages health information ensuring quality, accuracy and timely accessibility of patient medical information. Processes transcription reports for patient records. Processes release of information requests. Performs qualitative and quantitative chart analysis and validates admission/discharge census. Assigns correct ICD-10 CM codes for all diagnoses provided on all discharged charts. Maintains security and privacy of patient records and provide support to physicians and other disciplines within the organization.

KEY RESPONSIBILITIES:

• Coding: Assign the correct ICD-10 CM codes for all diagnoses provided on all discharged charts. Query physicians to verify correct ICD-10 CM diagnoses. Attend seminars or webinars to remain current on coding changes. Accurately follows coding guidelines and legal requirements to ensure compliance with both Federal and State regulatory bodies. Monitor the daily Missing Discharge Diagnosis Report from AIS. Code charts within 4 days of discharge.
• Does the accurate abstracting of patient’s information, and enters accurate discharge disposition of patients in AIS.
• Assigns/supplies correct ICD-10-CM and CPT, if asked, on all diagnoses provided in all patients’ charts.
• May be asked to supply HCPCS CODES on all procedures and services performed.
• Audits medical records to ensure proper coding completed and to ensure compliance with both federal and state regulatory bodies.
• Reports all cases with undetermined or missing primary diagnoses to the HIM Director.
• Coordinates and pull charts necessary for coding audits including Medicare coding audits.
• Maintains current Coding certification, if any.
• Maintains punctual work attendance and has flexibility in schedule and may be asked to flex when there are few charts to code.

· Monitor discharged patient charts: Run daily reports to validate patient discharges . Pull charts for review and analysis on a timely basis as required by policy and by regulation. Assemble and analyze discharged patient charts and review records according to department standards.

· Chart review: Identify chart deficiencies by tabbing for missing signatures and documenting what reports need to be dictated. Document findings of the deficiency on the audit form. Enter deficiencies into AIS. When charts have been completed by the physician, reanalyze and remove deficiencies from AIS.

· Chart maintenance and assembly: Create and maintain patient charts based on established department guidelines. Assist in retrieving charts for physicians or staff for completion. Retrieve and re-file the patient’s medical records, as required. File loose filing daily into the proper charts. Prepare charts for patient discharge process.

· Release of Information: Process all requests for medical records received by mail, fax, or phone according to State and Federal requirements, including HIPAA regulations. Ensure that the release of information is completed properly, timely, and valid. Facilitates gathering information needed by the Business Office needed for TARs

· Clerical Support: Assist in answering telephone and taking accurate messages. Pulling charts for physicians, nursing and other hospital personnel. Perform audits as requested.

· Transcription Reports: Assist in processing transcribed reports from outside transcription service. Assist in distributing transcribed reports to units for timely inclusion into the patient’s active medical record. Works with the physicians to answer questions regarding dictation or transcription. Ensures that errors by outsourced transcription company are corrected and referred to the HIM Director.

· Maintains confidentiality of her/his assigned AAR’s system username and password.

· Keeps good work ethics.

· Arranges coverage when planning out of town leave

· Works well and harmoniously with the rest of the HIM Staff

POSITION Requirements:

Knowledge and Experience:

· High school diploma or equivalent.

· CCS AHIMA Certification within 9 months of hire or completion of CAHIIM accredited program.

· One year of experience working with medical records preferred.

· Coursework specific to regulations pertaining to proper administration of medical records preferred.

· Demonstrated knowledge of patient privacy (HIPAA) relative to maintaining medical records required.

· Knowledge of medical terminology preferred.

· Knowledge of ICD-10 experience preferred.

· Has experience in using computer, Excel program and good typing skills

· Proficient in English language with at least good comprehension of the English language.

Skills and Abilities:

· Maintains confidentiality of patients at all times

· Sensitivity to and willingness to interact with persons of various social, cultural, economic and educational backgrounds.

· Proficiency with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel and PowerPoint.)

· Strong organizational skills with ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.

· Strong written and verbal communication skills.

· Strong interpersonal skills. Ability to work with people with a variety of background and educational levels.

· Ability to work independently and as part of a team.

· Good judgment, problem solving and decision-making skills.

· Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.

· Ability to work in a fast-paced, expanding organization.

Physical Requirements:

While performing the duties of this job, this position is frequently required to do the following:

· Use standard office equipment and access, input, and retrieve information from a computer. Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.

· Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.

· Frequent bending, squatting, kneeling, climbing with the use of a step stool and twisting. Lift and carry up to 20 pounds.

· Sit or stand for minimum periods of one hour at a time. Come and go from the work area repeatedly throughout the day.

· Give and follow verbal and written instructions with attention to detail and accuracy.

· Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.

· Vision: see details of objects at close range.

· Coordinate multiple tasks simultaneously.

Job Type: Full-time

Pay: $20.89 - $29.13 per hour

Benefits:

• 401(k)
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Work Location: In person