CODER

Health Information is looking for an individual to join their team to code.

The regular duties that are included in this position are:

• Accurately track all admissions/discharges (inpatient), including some outpatient for statistical purposes (i.e. daily census).

• Assist in chart assembly and perform chart analysis. Analyzes medical records of discharged patients for completeness and accuracy according to department and hospital policy and procedures.

• File completed charts and be able to retrieve charts.

• Maintain accurate medical record numbers.

• Ensure accurate transcription of medical records (history & physicals, discharge summary, operative reports, consultations, progress notes, etc.)

• Responsible for coordinating the release of medical information to all requesters, including patients, physicians, and other healthcare providers. Maintain a computerized log of all requests.

• Reviews medical record thoroughly to ascertain all diagnoses/procedures. Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on medical record. Codes all diagnoses/procedures in accordance to ICD-10 and HCPCS coding principles and the Coding Manual. Refers medical record to Director, if there is a question regarding the diagnoses/codes.

The preference would be a candidate with experience/knowledge of coding. Certification is preferred, but not required.

Position Overview

The Health Information department is seeking a dedicated professional to manage medical record documentation, patient tracking, and clinical coding. This role is essential for maintaining accurate hospital statistics, ensuring compliance with hospital policies, and facilitating the seamless handling of patient health information across various departments.

Key Responsibilities

The successful candidate will be responsible for tracking inpatient and outpatient admissions and discharges, assembling and analyzing medical records for completeness, and managing physical and digital file retrieval. Additional duties include transcribing medical documentation, coordinating the secure release of health information to authorized requesters, and meticulously assigning ICD-10 and HCPCS codes to all diagnoses and procedures.