CODER/HEALTH INFORMATION MANAGEMENT TECHNICIAN/Full-time

POSITION SUMMARY:

The HIM Coder/Technician II is responsible for ensuring patient record documentation meets state and federal regulations and physician documentation supports coding. This position will apply all official coding guidelines when assigning diagnostic and procedure codes for both inpatient and outpatient accounts based on health record documentation. This position will assist the HIM Manager with daily activities of the department, including release of information (ROI), scanning and validating paper documents, compiling statistics, gathering data for trauma and cancer registries, filing, transcribing, and maintenance of data dictionaries.

SCHEDULE: Full-time; M-F, 7am-3:30pm

SSENTIAL JOB DUTIES/REQUIREMENTS:

• Ensure patient record documentation meets state and federal regulations for content, completeness, and timeliness.
• Code ED, Outpatient, and Inpatient accounts correctly to ensure coding guideline are followed for appropriate reimbursement, utilizing Alpha II coder, Code Correct, and AMA ICS-10-CM, and HCPCS coding books.
• Accurately completes chart review to ensure accuracy and completeness for analytical, statistical, and patient care purposes.
• Call physicians and ancillary departments to get correct diagnosis to complete coding procedures.
• Physically locate and wait for physicians, nursing staff, and therapists to obtain correct diagnosis to complete coding procedures.
• Assures timely completion of chart deficiencies by promptly recording such deficiencies in the ICR desktop and by providing healthcare staff with the information they require to complete the deficiencies.
• Receiving calls from ancillary departments, physician offices, etc to get correct ICD-10 and CPT coding.
• Transcribes “STAT” dictations as a priority and other transcription as needed.
• Refer inconsistent or incorrect coding by provider to management when a trend or pattern is identified.
• Respond and process all requests for copies of medical records from other healthcare facilities, over the phone, and walk-in requests, ensuring correct requests are filled out properly.
• Responsible for establishing and maintaining healthy interpersonal relationships with all staff members.
• Recognize the important part this position plays in Performance Improvement of the ongoing delivery of patient care.
• Reacts properly and follows correct policy and procedure in an emergency and/or disaster.
• Must wear Personal Protective Equipment (PPE) as situations require maintaining Infection Control standards set by hospital.

POSITION QUALIFICATIONS:

• High School Diploma required plus CCS coding certification from AAPC or AHIMA, or accredited college, or a minimum of 5 years of applicable ICD diagnostic, CPT procedural, and HCPCS coding in a hospital or diverse specialty physicians office.
• RHIT certification preferred.
• Experience interpreting a variety of instructions in written, oral, diagram, or schedule form.
• Must have advanced knowledge of Medical Terminology and excellent interpersonal skills and communication skills both written and oral.
• Previous experience capturing data and analyzing quality measures, case mix index, and health record documentation compliance.
• Skilled in data analysis, research, and error-correction
• Strong organizational and teamwork skills.
• Ability to effectively present information and respond to questions concerning statistics, coding, and transcription.
• Advanced computer skills in Microsoft programs, Word, Excel, Outlook and Electronic Medical Records (EMR), Meditech or EPIC preferred. Must keyboard at 50 wpm.