Medical Records Coder 1

Job Summary

Evaluate patients records, work to resolve inaccurate charges, and assign appropriate diagnoses & procedure codes using the coding systems according to HIPPA regulations. Abstract pertinent data from patients' clinical records. Review records for reimbursement purposes and to ensure quality control.

Responsibilities

• Read and interpret referred outpatient, series, and ED medical record entries to identify all diagnoses and surgical procedures.
• Assign appropriate ICD-10, ICD-9-CM, and CPT-4 codes in compliance with recognized coding principles and department policies.
• Determine appropriate diagnostic and procedural sequencing in compliance with UHDDS guidelines.
• Effectively utilize the APCpro features of 3M with the 3M encoder and grouper software to identify appropriate assign modifiers, make appropriate changes to charges, notify departments to make changes, identify missing documentation, and prepare the account as a clean claim for billing to the third party payer.
• Responsible for the accurate and timely entry of all abstracted and coded date into the computer system.
• Comply with HCFA's Medicare code edits.
• Ensure quality and accuracy of records for appropriate reimbursement.
• Verify and correct any data discrepancies by initiating communication with physicians and other hospitals personnel.
• Participate in the Coding Hotline by responding to callers+ needs for coding advice, identify callers needs that must be referred to a higher level of coding skill, and overall act as a liaison between coding and other departments that need coding services.

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department's identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities

(Essential duties common to all positions)

1. Maintain and document all applicable required education.

2. Demonstrate positive customer service and co-worker relations.

3. Comply with the company's attendance policy.

4. Participate in the continuous, quality improvement activities of the department and institution.

5. Perform work in a cost effective manner.

6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.

7. Perform work in alignment with the overall mission and strategic plan of the organization.

8. Follow organizational and departmental policies and procedures, as applicable.

9. Perform related duties as assigned.

Education

• High School Diploma or GED (Required)

Experience: None

Work Schedule: Days

Status: Full Time Regular 1.0

Location: Document Center Building

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Tamara B. Young tammy.young@vandaliahealth.org