What are the responsibilities and job description for the HIM CODER position at Connally Memorial Medical Center?
Summary Under general supervision and according to established procedures, assigns diagnostic codes to medical record information. Codes charts under the ICD 9 CM and HCPCS System for statistical and DRG assignment purposes. Abstracts required data into hospital abstracting system. The outcome of information gathered is used to determine the hospital database and reimbursement of hospital claims.
Essential Duties and Responsibilities include the following. Other duties may be assigned.
- Abstracts and codes diagnoses, operations, and procedures from health records by using appropriate classification systems, standards, and procedures.
- Prepares statistical reports required by applicable legal, accrediting, and/or licensing regulations and hospital policy.
- Assigns patient severity of illness index ratings, supplemental codes, and other data as necessary.
- Compiles information and data from health records and computer systems for use in the evaluation of quality of care and utilization review.
- 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 and maintains logs, reports, and statistical records, and researches records to locate health data as requested.
- Maintains and utilizes 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.
Education and/or Experience
Associate's degree (A. A.) or equivalent from two-year college or technical school; or six months to one year related experience and/or training; or equivalent combination of education and experience.
Must be able to perform concurrent chart review for proper DRG estimations for reimbursement. Must be educated in Medicare, Medicaid, and other insurance reimbursement guidelines.
Certificates, Licenses, Registrations
Equivalent to an associate's degree in medical information technology (with course work in medical terminology, anatomy, physiology, disease processes, ICD 9 CM coding and prospective payment) required.
RHIT, RHIA, or CCS required.
Education and/or Experience
- Associate's degree (A. A.) or equivalent from two-year college or technical school; or six months to one year related experience and/or training; or equivalent combination of education and experience.
- Must be able to perform concurrent chart review for proper DRG estimations for reimbursement. Must be educated in Medicare, Medicaid, and other insurance reimbursement guidelines.
Certificates, Licenses, Registrations
- Equivalent to an associate's degree in medical information technology (with course work in medical terminology, anatomy, physiology, disease processes, ICD 9 CM coding and prospective payment) required.
- RHIT, RHIA, or CCS required.