Medical Records Coder Senior

Medical Records Coder Senior

Requirements

• Associate’s degree or equivalent Medical Information Technology (with course work in medical terminology, anatomy, physiology, disease processes, ICD 9 CM coding and prospective payment)
• 2 years of relevant experience coding experience in an acute care setting

Responsibilities

• Provides technical coding support to the Inpatient Coding Staff and coordinates daily workflow based on the needs of the department and as directed by the Manager of Coding
• On a daily basis, submits to the Manager of Coding departmental statistics such as coder productivity and uncoded figures
• Works with the Coding Manager and Coding Educator to identify and resolve coding issues
• Reports all aged accounts to the Director of Medical Records and Manager of Coding. Works with the Medical Records Staff and/or Physician to obtain all necessary documentation to code all accounts in a timely manner
• Provides coding/abstracting support as directed by the Manager of Coding
• Analyzes patient medical records and interprets documentation to identify all diagnoses and procedures. Assigns proper ICD 9 CM and HCPCS diagnostic and operative procedure codes to charts and related records by reference to designated coding manuals and other reference material
• Applies Uniform Hospital Discharge Data Set definitions to select the principal diagnosis, principal procedure and other diagnoses and procedures which require coding, as well as other data items required to maintain the Hospital data base
• Applies sequencing guidelines to coded data according to official coding rules
• Assesses the adequacy of medical record documentation to ensure that it supports the principal diagnosis, principal procedure, complications and comorbid conditions assigned codes. Consults with the appropriate physician to clarify medical record information
• Answers physicians/clinician questions regarding coding principles, DRG assignment and Prospective Payment System. Assists Finance, Data Processing and other departments with coding/DRG issues
• Remains abreast of developments in medical record technology by pursuing a program of professional growth and development, attending educational programs and meetings, reviewing pertinent literature and so forth
• Attends all required Safety Training programs and can describe his/her responsibilities related to general safety, department/service safety, specific job-related hazards
• Follows the Hospital Exposure Control Plans/Bloodborne and Airborne Pathogens
• Demonstrates respect and regard for the dignity of all patients, families, visitors and fellow employees to ensure a professional, responsible and courteous environment
• Promotes effective working relations and works effectively as part of a department/unit team inter and intra departmentally to facilitate the department’s/unit’s ability to meet its goals and objectives
• Acts as a liaison with lead technician(s) and provides employee performance feedback as necessary. Performs quality monitoring and works on quality improvement initiatives and projects

Preferred Qualifications

• 1 of 4 certifications preferred: CRT-Registered Health Information Administrator (RHIA) – AHIMA American Health Information Management Association
• CRT-Registered Health Information Technician (RHIT) – AHIMA American Health Information Management Association
• CRT-Coding Specialist, Certified-Physician Based (CCS-P) – AHIMA American Health Information Management Association
• CRT-Coding Specialist (CCS) – AHIMA American Health Information Management Association