Description

JOB SUMMARY

Under the general direction of the Health Information Management Coordinator, the HIM Coder will collate and code procedures and tests and ensure completeness and accuracy in the coding process in a timely manner and will support associated medical records functions in accordance with TJC, federal, state, and local guidelines, organizational and departmental policies and procedures. Communicates with medical staff, other departments, and outside agencies while maintaining confidentiality. Position requires self-motivation, creativity, and capabilities to function in a semi-autonomous role within a fast paced and dynamic environment.

STANDARDS OF PERFORMANCE

1. Ensures adherence to proper infection control, OSHA and safety standards.

2. Reports hazardous conditions and equipment outages immediately to manager and if necessary, directly to Maintenance, and posts an entry into the maintenance log/help desk.

3. Requests any additional charges, test results, etc., from various departments to ensure timely coding, daily.

4. Maintains a 95% accuracy rate on all coded records taking into consideration all test result and information provided by caregivers.

5. Code all records within three days of discharge unless records require more information for coding purposes.

6. Must be able to code at least 28 records per hour.

7. Utilizes physicians and/or personnel to expedite any problems or questions that exist when necessary.

8. Follows up on questions and/or problems to code the record in a timely manner.

9. Maintains the department and work area in a neat, clean, and organized manner.

10. Receives, places, and transfers calls using appropriate telephone etiquette.

11. Handles telephone requests appropriately.

12. Demonstrates a consistent level of performance, and a steady level of productivity.

13. Participates in continuing education.

14. Handles coding for Method 2 Billing.

15. Complete the Performance Improvement Report for Method 2 Billing

16. Print all reports, MR Billing Report, Approved Claims Report, claims with missing information insurance report, Patient Index Report, Exceptions Report, and Incomplete Registration.

17. Document coding productivity.

18. Research policies for medical necessity.

19. Handles Business Services request on claims.

20. Scan reports/records/data.

21. Handle the QA report from Business Office Services once a month.

22. Maintain the cancer registry.

23. Performs other duties as necessary/required with scope of position and training.

Requirements

Minimum Level of Education: Education level equivalent to completion high school.

Formal Training: None.

Licensure, Certification, Registration: RHIA, RHIT, CCS, and or CPC required. CCA and CPC-A certification will be accepted but must obtain the certifications listed above within the timeframe set up by AAPC or AHIMA within 12 months of hire date.

Work Experience: Six months to one-year experience in coding.

Tools and Equipment Used:

Calculator, personal computer, telephone, facsimile machine, paper shredder, copier, printer, standard office equipment, encoding software, ICD-10-CM and CPT Coding Manuals.