Medical Records Coder

Medical Records Coder

The Medical Records Coder is responsible for assigning ICD-10-PCS diagnostic and procedural codes to patient accounts codes and abstracts hospital medical records for maintenance of disease indices, internal and external reporting, research, compliance with federal, state and other regulatory agencies, and for billing and reimbursement. Uses various coding manuals and computer encoder. Confirms appropriate DRG assignments. Safeguards and preserves the confidentiality of patient identifiable information in accordance with hospital and department policy. Resolves error reports associated with billing process, identifies and reports error patterns, and, when necessary, assists in design and implementation of workflow changes to reduce billing errors.

Roles and Responsibilities

Essential Functions:

• Assigns appropriate codes using International Classification of Disease system (ICD-10) and/or Current Procedural Terminology (CPT) for diagnosis, procedures, and services.
• Correctly codes claims based on the services a patient receives in order to obtain reimbursement from insurance or government healthcare programs.
• Reads and analyzes patient records, extracting precise information from documentation, test results and reports.
• Requests diagnosis from physicians when not recorded on discharge and in cases where information is incomplete.
• Maintains confidentiality regarding patient care information and chart contents.
• Informs administrator of any incongruences noted in the chart record.
• Clarifies diagnosis, conditions, and treatment information by working with the physician according to company policy and procedure as needed
• Processes physician reports needed to code appropriately and accurately.

Education/Experience/Skill Requirements

• High school diploma or equivalent required. Certificate or Associate's Degree in medical coding or related field preferred.
• Two or more years' of medical billing/collections/coding required.
• Ability to crossover between all coding types and maintain a coding accuracy.
• A working knowledge of coding principles as it applies to both inpatient and outpatient coding and background in medical terminology, pathophysiology, anatomy & physiology.

Licenses/Designations/Certifications

CCS, RHIT or approved Medical Coding Certificate required.

Work Location

This position is onsite at the facility and is not a remote position.

Supervisory Requirements

This position is an Individual Contributor.

Why Palms Behavioral Health? Palms Behavioral Health offers a comprehensive benefit plan and a competitive salary commensurate with experience and qualifications. Qualified candidates should apply by submitting a resume. Palms Behavioral Health is an EOE.

Veterans and military spouses are highly encouraged to apply. Summit BHC is dedicated to serving Veterans with specialized programming at our treatment centers across the country. We recognize and value the unique strengths of the military community in supporting our mission to serve those who have served.