Palm Drive Hospital

JOB DESCRIPTION Medical Records Coder

Job Summary (Purpose the Position Exists): Performs coding functions in Department, using either ICD9-CM or CPT-4 coding systems. Familiarity with HBOC/Spectron Patient Information System, 3-M encoder, DRG and APC assignment.

Education, Training and Licenses Required: Registered Health Information Technologist (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), or on progression program for attaining CCS credential (Certified Coding Specialist) through AHIMA Independent Study. Must have adequate coding experience to code without supervision.

Experience Required: At least two years of college with proven proficiency in medical terminology, scientific nomenclature, and advanced coding in ICD-9 and CPT methodologies.

Knowledge/Skills/Abilities Required: Ability to abstract and encode data using computer skills and encoder program; knowledge of common Medicare and billing codes for reporting purposes; typing skills of at least 45 wpm. Knowledge of HIPAA regulations.

Equipment Knowledge Required: Windows 98, Patient Information Systems, Encoding systems, phones & Fax machines

Working Conditions (Noise, Environmental, Demands, Shift, Setting, Human Interface, etc.): Monday through Friday, day shift.

Confidentiality Requirements: I understand that any and all information regarding hospital, patient, and employment matters are disclosed or learned by me in confidence. I agree that during and after my term of employment, I will not directly or indirectly disclose this information, other than to an authorized employee of Palm Drive Hospital.

Safety Requirements: Employees are responsible for all aspects of the hospital safety and health program including compliance with safety rules and regulations, remedying unsafe working conditions, and for continuously practicing safety while performing duties.

Physical Requirements: See “Description of Physical Demands” binder in Human Resources.

Supervisory Requirements (if applicable): This position supervises a staff of 0 , including part time employees. I understand I will be reviewed on my competence as a supervisor, including but not limited to communication skills, delegation of tasks, prioritization of work, leadership, problem solving, budgeting and reviewing of my staff's performance

1. Codes charts accurately with minimal errors utilizing ICD-9-CM and CPT codes.

2. Exhibits advanced knowledge of ICD-9-CM and CPT coding practices and conventions.

3. Inputs patient information into the computer accurately (abstracting).

4. Assists other departments as needed in order to accurately drop a patient bill.

5. Consults with physicians to obtain clarified information in order to accurately code the patient account.

6. Uses fax machine for communication with physicians regarding documentation and coding.

7. Runs reports monthly to assess what is still uncoded/unbilled. Works with various departments to capture needed reports/data in order to code account.

8. Learns new coding rules and regulations and retains knowledge.

9. Maintains awareness of changes in procedures and protocols.

10. Assists with correction of data as requested in response to edits received from OSHPD or other data users.

11. Is accountable for maintaining the confidentiality of information gained in the process of one’s work, either within or outside the HIM Department.

12. Can be depended upon to modify work schedule as required for Medical Records / HIM Department coverage on a temporary basis.

13. Works under pressure of frequent interruptions and stat requests.

14. Is willing to lend assistance to others.

15. Performs department filing duties as assigned by director/supervisor.

16. Performs other duties as assigned by director/supervisor.