Medical Records Coder - Certified

Health Information Management (HIM) IP and/or OP Department

FLSA: Hourly

Responsible to: Health Information Manager

Responsible for: Does not supervise other employees

Interrelationships: Works cooperatively with all hospital departments and the Medical Staff

Job Summary:

Assigns diagnostic and procedure codes to records of discharged patients and forwards reports as required. Also, performs other duties as directed by the HIM director.

Job Qualifications:

Experience: Previous directly related training and experience preferred

Education: High School or equivalent

Req. Cert./ Certification as RHIT preferred but not required (must be attending classes to obtain in future though). Coding Certification required.

Job Duties:

(This list may not include all of the duties assigned.)

1. Reviews patient's charts and assigns appropriate ICD-10-CM, ICD-10-PCS and CPT codes for OP charts.
2. Determines the sequence of diagnoses according to uniform hospital discharge data. Incorporate use of LCDs and NCDs for medically necessary services. Able to use NCCI edits and MUEs for correct coding.
3. Inputs abstract data and codes into computer.
4. Assists in maintaining electronic health record.
5. Good communication skills with fellow departments on reports/charges needed on an encounter.
6. Verify scanned image quality as coding charts for accuracy on appropriate FIN, etc.
7. Completes release of information requests as necessary.
8. Participates in educational programs and in-service meetings.
9. Back-up for birth certificate completion.
10. Attends meetings and training as required
11. Any other duties as requested by Department Director