Description

 Summary Under general supervision and according to established procedures, assesses the readiness of medical records for scanning. Assigns charts to appropriate coders. Scans, logs, mails, and enters diagnostic codes upon receiving codes from outside coders; finalizes records for permanent file; files records. 
Essential Duties and Responsibilities include the following. Other duties may be assigned.

• Analyzes and reviews medical records for completeness and accuracy of documentation according to specified standards.
• Ensures all daily discharges are scanned and indexed within 24 hours
• Assist with release of information walk in and scanning of release of information documentation
• Abstracts and codes clinical data such as diseases, operations, procedures, and therapies on medical records according to specified standards.
• Assigns patient severity of illness index ratings, supplemental codes, and other data as necessary.
• Monitors completion of medical records in accordance with time standards.
• Audits incomplete records and prepares reports on delinquencies.
• Confers with doctors, nurses, and other health personnel to assure complete, current, and accurate medical records.
• Compiles, maintains, and reviews logs, reports, and statistical records, and researches records to locate health data as requested.
• Maintains and utilizes a variety of health record indexes and storage and retrieval systems.
• Operates computer to process, store, and retrieve health information.
• Assists in identification of medical records needed for research using both manual and computer indexes.
• Assists Medical Record Director in special studies or research, as needed.
• Trains clerical staff in medical record processing activities.
• Prepares input for computerized medical information systems and for processing vital statistics, insurance, and other forms and documents.

Requirements

Education and/or Experience

One year certificate from college or technical school; or three to six months related experience and/or training; or equivalent combination of education and experience.

Certificates, Licenses, Registrations

 High School Graduate or GED

Up to two years work related experience in a Healthcare setting.

One Year of coding experience or a certificate of training or attendance in an accredited coding course.

Typing / Computer skills

Knowledge of Medical Terminology

Knowledge of Coding Principals