POSITION SUMMARY: Compiles and maintains medical records of patients within the health information system.
Essential Duties and Responsibilities
Completes coding process; accurately assigns ICD-9, HCPCS/CPT and APC codes within allotted timeframes.
Conducts coding reviews on extended care resident accounts.
Knowledgeable regarding various computer systems used to support medical record documentation (Chartlink, CPSI, Dictaphone).
Reviews patient medical records for completeness, assembles records and distributes according to established procedures.
Completes neoplasm reporting to State Department of Health as required.
Files and pulls patient medical records in terminal digit and straight numeric system as necessary.
Maintains thorough knowledge of coding role in revenue cycle management and impact on A/R days benchmark.
Performs others duties as assigned.
- High School Diploma or General Education Degree (GED).
- Training in medical transcription and ICD 9-CM/CPT 4 coding or related field.
- A minimum of six months experience.
- Types accurately at a minimum of 60 words per minute.
Reports directly to the Coding Supervisor.
Regular contact with Fiscal Services, IT, Medical Staff and Ancillary Service departments.
Occasional contact with insurance carriers, government and legal agencies and patients.
Work is performed largely in a pleasant hospital environment with minimal chance for personal injury.
Occasionally works near moving mechanical parts.
The noise level in the work environment is usually moderate.
Frequently required to sit and stand.
Occasionally required to stoop, kneel and crouch.
Required to use hands to handle or feel objects, tools or controls.
Frequently required to lift and/or move up to 10 pounds of department supplies and equipment.
Occasionally required to lift and/or move up to 25 pounds of department supplies and equipment.
Requires specific vision abilities for far vision, near vision, depth perception, colors, accommodation and peripheral vision.
Vision correctable to 20/40.
Acknowledgement: This job description/evaluation describes the general nature and level of work performed by an employee assigned to this position. It does not state or imply that these are the only duties and responsibilities assigned to the job. The employee may be required to perform other job-related duties as requested by the department manager or administration. All requirements are subject to change over time and to possible modification to reasonably accommodate individuals with disabilities.