Radiology Coder - EngageMED Corporate

POSITION DESCRIPTION

Position Title: Coder

Department: Clinical

FLSA Status: Non-Exempt

Reports To: Clinic manager

Position Summary:

Under direct supervision, Coder is responsible for abstracts and codes patient records in compliance with coding, billing and data collection guidelines of the organization. This role is typically responsible for less complex coding by established clinical protocols.

Supervisory Responsibilities:

• None

Duties/Responsibilities:

• Accurately abstract information from the medical records into the appropriate coding systems, ensuring compliance with established guidelines.
• Determine the most appropriate diagnosis after a thorough review of the medical records.
• Works closely with practice staff with regards to coding and assignment of MS-DRGs (Diagnosis Related Group) and APCs (Ambulatory Payment Classification).
• Code medical records using ICD-10-CM and CPT-4 coding rules and guidelines. Ensure through and compliant coding to support patient records and submission of billing for payment.
• Accurately sequence diagnostic and procedural codes according to organization specified procedures and assigns MSDRG/APC as appropriate. Provide codes to various departments upon request.
• Enter and validate charges using appropriate tools and validates diagnoses with the medical documentation provided.
• Compare charges on accounts with the procedures coded and identifies any discrepancies. Notifies Coding Manager of any discrepancies’ and collaborates as needed to rectify the account.
• Visit assigned clinics as needed to maintain strong relationships with providers and staff.
• Role model the behaviors expected by EngageMED.
• This position reviews clinical documentation for procedures like X-rays, MRIs, CT scans, ultrasounds, and nuclear medicine to ensure accurate clinical tracking, regulatory compliance, and optimal revenue cycle reimbursement. The ideal candidate possesses deep knowledge of anatomy, radiological medical terminology, and complex modifier applications (such as professional vs. technical components).
• Other duties as assigned

Required Skills/Abilities:

• Teamwork Orientation: works cooperatively & collaboratively with others toward the accomplishment of shared goals.
• Service Orientation: desire to serve and focus ones efforts on discovering and meeting the needs of internal and external customers.
• Achieves Results: reflects a drive to achieve and outperform. Continuously looking for improvements. Accepts responsibility for actions and results.
• Learning and Growth: has a commitment to continuous professional and organizational learning
• Communication: practices attentive and active listening and can restate opinions of others; communicates messages in a way that has the desired effect.
• Ability to perform EKGs, draw blood and administer injections.
• Ability to effectively communicate to staff and patients.

Education and Experience:

• Must have a high school diploma or equivalent required.
• Associate’s degree in related field preferred.
• Completion of college level courses in medical terminology, anatomy and physiology, disease processes and pharmacology preferred.
• Completion of ICD-10 or CPT coding course a plus.

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• May require prolonged periods of standing, moving, and bending.
• Must be able to lift up to 50 pounds at times.

Disclaimers

• This job description reflects EngageMED’s assignment of essential functions, it does not prescribe or restrict the tasks that may be assigned.
• Critical features of this job are listed above. They may be subject to change at any time due to reasonable accommodation or other reasons.

Coworker Print Name: ___________________________________________________________________________

Coworker Signature: _______________________________________________________Date: ________________