What are the responsibilities and job description for the Coder Abstractor - Health Information Services position at Oaklawn Hospital?
Job Summary: Under limited supervision, codes and abstracts patient records using the appropriate coding/abstracting system. Communicates with Medical Staff and hospital staff to improve the documentation to support the coding process.
Essential Functions:
- Consistently uses an outward mindset and puts forth exemplary effort in accomplishing his/her goals and objectives in a manner that helps others to achieve their goals and objectives.
- Code outpatient (for example day surgery, observation, emergency room, outpatient service, diagnostic) records using the appropriate coding system for diagnoses (ICD-10) and procedures (CPT & PCS)
- Maintain coding quality as evidence by coding accuracy rate.
- Uses the appropriate encoder to optimize reimbursement within the accepted coding guidelines and rules.
- Communication with physicians, physician offices and hospital staff to obtain clarifying documentation for correct coding.
- Applies charges on identified patients (for example ED levels, Infusions, clinic visits) based on the record documentation.
- Assists physicians, physician offices, medical staff and hospital personnel with HIM/coding/charging related questions.
- Assists with other HIM related processes i.e. release of information, deficiency analysis etc. as needed.
Minimum Qualifications: CCA or equivalent certification. Relevant clinical or medical experience and CCA obtained with 1 year of hire.
Knowledge, Skills & Abilities: Previous experience preferred. Knowledge of electronic record systems; knowledge of medical terminology, anatomy, physiology and disease processes; knowledge of charging processes; adept in ICD-10 and CPT coding; strong interpersonal relationships and skilled in assessing and prioritizing multiple tasks, projects and demands, operating a personal computer utilizing a variety of software applications, keyboarding skills and ability to work independently, as well as to accept direction on given assignments.
Working Conditions: Work is generally performed within an office environment, with standard office equipment available.
Physical Requirements: Constantly sit, see/visual acuity, handle/grasp/feel, talk/hear. Occasionally lift/carry 1 to 25 lbs.
