Medical Coder

TITLE: MEDICAL CODER

DEPARTMENT: H.I.M

SUPERVISOR: H.I.M. DIRECTOR

CLASSIFICATION:FULL TIME NON-EXEMPT

POSITION SUMMARY: This incumbent performs highly technical and specialized functions. The employee reviews, analyzes, and codes diagnostic and procedural information to ensure compliance with established coding guidelines, third party reimbursement policies and regulations. The coding function is a primary source for data and information used in health care today, and promotes provider/patient continuity, accurate database information, and the ability to optimize reimbursement.

ESSENTIAL FUNCTIONS:

• Responsible for reviewing patient charts and entering pertinent patient data into RPMS database.
• Compiles, sorts and verifies accuracy of data entered into the Electronic Health Record.
• Assigns and sequences ICD9CM/CPT/HCPCS codes to diagnoses and procedures for documented information.
• Assures the final diagnoses and operative procedures as stated by the physician are valid and complete.
• Abstracts all necessary information from health records to identify secondary complications and comorbid conditions.
• Quantitative analysis Performs a comprehensive review for the record to assure the presence of all component parts such as: patient and record identification, signatures and dates where required, and other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.
• Qualitative analysis Evaluates the record for documentation consistency and adequacy. Ensures that the final diagnosis accurately reflects the care and treatment rendered.
• Analyzes provider documentation to assure the appropriate Evaluation & Management (E & M) levels are assigned using the correct CPT code.
• Audits each visit to ensure all GPRA information is captured and recorded appropriately.
• Compiles data from client records for periodic inquiries and statistical reports; corrects daily census report if necessary.
• Performs related work as required

All LCTHC employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the LCTHC policies and procedures as they may from time to time be updated.

QUALIFICATIONS:

• High School diploma or GED
• Two years of coding experience using ICD9CM, CPT, HCPCS, and IHS coding conventions or equivalency.
• CCS, CCSP or CPC certification is preferred.
• Advance knowledge of medical terminology, abbreviations, techniques and surgical procedures; anatomy and physiology; major disease processes; pharmacology; and the metric system to identify specific clinical findings, to support existing diagnoses, or substantiate listing additional diagnoses in the medical record.
• Requires the knowledge of the business use of computer hardware and software to ensure the effectiveness and quality of the processing and presentation of data.
• Requires skill in the use of a wide variety of office equipment including: computer, typewriter, calculator, facsimile, copy machine, and other office equipment as required.
• Must be able to follow instructions and work independently.
• Knowledge of the regulations regarding client confidentiality

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Sitting / Mobility: Approximately 70% of time is spent working at a desk. Balance of time (approximately 30%) is spent moving around work areas.

Communication: Ability to effectively communicate with co-workers, Board members, members of outside agencies, in person, by telephone, and by email.

Vision: Ability to effectively use a computer screen and interpret printed materials, memos, and other appropriate paperwork.

Lifting / Carrying: Ability to occasionally lift and/or move objects weighing no more than 25 pounds.

Stooping / Kneeling: Ability to access files/stock supplies in low cabinets and shelves.

Reaching / Handling: Ability to input information into computer systems and retrieve and work with appropriate paperwork, equipment, and supplies. Use of standard office equipment, including computer, telephone, calculator, copiers, and fax. Work is performed in an office/clinic environment; continuous contact with other staff and the public.

INDIAN PREFERENCE: Preference may be given to qualified Native American Indians according to the Indian Preference Hiring Act, CFR 25 USC 472. Other than Indian Preference, Lake County Tribal Health Consortium, Inc. adheres to all provisions of the Equal Employment Opportunities Act.

NOTICE OF DRUG-FREE WORKPLACE ACT REQUIREMENT: LCTHC is committed to maintaining a drug-free and alcohol free workplace. LCTHC believes that a healthy, productive workforce free from the effects of drugs is very important to all employees and patients. Substance abuse is incompatible with the health, safety, efficiency and the success of LCTHC. Employees who are under the influence of compromising LCTHC’S interests, endanger their own and the health and safety of others and can cause a number of other work-related problems. As a condition of employment, each applicant receiving a job offer from LCTHC must take and pass a required drug screen test.

HIPAA Health Insurance Portability and Accountability:

This act was enacted to deal with three main areas with regard to patient information.

• Security of health information
• Standards of electronic transactions
• Privacy of individually identifiable health information

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.

Lake County Tribal Health is an At-Will Employer. Either the employee or LCTHC can terminate the employment at will, without advance notice, at any time, with or without cause