Outpatient Coder

Medical Record Technician

Under the direction of the HIM Manager, maintains medical record integrity through the processing of outpatient medical records including analyzing, coding, and data entry.

Full-time, benefited position working 72 hours per two week pay period. Days of work are Monday - Friday with no nights, weekends or holidays. This can be a hybrid role, requires to be on-site half the time.

Job Functions:

• Demonstrates an understanding of coding conventions; adheres to coding guidelines and refers to current literature regarding coding questions. Contacts physicians as necessary to obtain additional information.
• Analyzes outpatient medical records.
• Codes outpatient diagnoses and procedures utilizing ICD-10-CM and CPT-4 coding classification systems.
• Performs physician coding for the radiologist and ER contract physicians.
• Verifies assignment of nursing E/M levels in the ER.
• Utilizes the encoder and stays proficient with this system.
• Types and distributes birth certificates
• Assists hospital staff, physicians, patients, and guests with inquiries regarding medical information.
• Performs other related duties as assigned or requested.

Qualifications/Requirements for This Position:

1. Preparation and Training - High school graduate with completion of Health Information Technician/Management and/or Coding Curriculum, including working knowledge of anatomy, ICD-10-CM coding courses.
2. Work Experience - No experience required with education as defined above. A minimum of two years' experience, without education, employed in a Medical Record Department performing tasks related to this job description.
3. Attendance - Punctual and regular attendance is an essential responsibility of each employee at JRMC. Employees are expected to report to work as scheduled, on time and prepared to start working. Employees are also expected to remain at work for their entire work schedule.
4. Analytical Ability - Employee must possess strong analytical ability to assign correct codes to diagnoses and procedures.
5. Independent Judgement - Responsible for maintaining standards of this position. Manager shall be contacted when questions arise.
6. Contacts with Others - Communicates well with co-workers, other hospital staff, physicians, and guests.
7. Supervising the Work of Others - None
8. Responsibility for Welfare of Others - Employee must realize the importance of confidentiality at all times. The identification of patient medical records must be accurate and concise.
9. Mental / Visual Effort - Must be able to speak and write the English language in an understandable manner. Must be able to see and hear or use prosthetics that will enable these senses to function adequately to assure that the major requirements of this position can be fully met. Must be in good general health and demonstrate emotional stability. Visual acuity and color perception necessary for performing routine procedures.
10. Working Conditions - Participates in and complies with JRMC Safety Management Program. Maintains knowledge of and observes Standard Precautions. OSHA Job Classification: Category II position, employee does not have exposure to bloodborne pathogens.
11. Physical and Sensory Effort - This position requires frequent sitting to perform the major responsibilities. Must be able to move around in aisles less than 30 inches in width and frequently file records at a maximum height of six feet.
12. Promotion - No formal line of promotion
13. Background Check - A comprehensive background check and drug screening will be conducted as a condition of employment for this role.
14. Drug Screen - A urine drug screening is required for all positions and must be completed within 30 days of the date of hire.
15. Physical Requirement - These are physical requirements of the position that may be performed as part of daily duties. Inability to meet one or more of these physical requirements will not automatically disqualify a candidate or employee from the position. Upon request for reasonable accommodation, JRMC may be able to adjust or excuse one or more of these requirements, depending on the requirement, the essential functions to which it relates and the proposed accommodation.

Employee Requirements:

• Visual Observation - Continuously
• Standing - Occasionally
• Walking - Occasionally
• Sitting - Continuously
• Hands and Finger Dexterity - Continuously
• Reaching with Hands and Arms - Continuously
• Climbing - Rarely
• Stooping/Kneeling/Crouching/Crawling - Rarely
• Hearing/Listening - Continuously
• Tasting or Smelling - Never
• Working Inside - Continuously
• Working Outside - Never
• Working in Extreme Heat - Never
• Working in Extreme Cold - Never
• Working with Hazardous Materials - Never
• Noise - Rarely
• Working in Dirt/Dust - Never
• Driving - Never

Lifting / Carrying / Pushing / Pulling:

• Up to 10 pounds - Occasionally
• Up to 25 pounds - Occasionally
• Up to 50 pounds - Rarely
• Up to 75 pounds - Never
• Up to 100 pounds - Never
• Over 100 pounds - Never