CODER, MEDICAL RECORDS
Job Description
Summary
Reviews patient medical records for relevant diagnostic and procedure information and assigns corresponding codes according to standard coding guidelines maintaining productivity. Assists with the maintenance of various patient indexes and databases. Provides patient information retrieval assistance to researchers and others as needed.
Essential Responsibilities and Duties
1. Researches medical record to develop the most complete codes for all diagnoses and procedures.
2. Applies knowledge of anatomy, physiology, disease process and medical terminology to interpret the record and select accurate codes.
3. Interprets and translates clinical documentation from the medical record into diagnostic and procedural codes; abstracts data into computer data base.
4. Responsible for thoroughly knowing and utilizing all coding systems both inpatient and outpatient according to the most recent rules, regulations and conventions.
5. Contacts physicians as necessary to request more complete information and/or clarification in order to completely code the patient records.
6. Maintains an accurate and timely computerized database utilizing prescribed abstract format.
7. Maintains coding skills and professional credentials with appropriate continuing education by reading and applying coding materials and policies.
8. Prepares or assists with the preparation of statistical or other special reports relating to patients, diseases and treatments as needed.
9. Performs audits, quality checks and provides training to the trainees as required.
10. Acts at all times as a service representative of the department. Provides cross-coverage for other positions in the department as requested by the management.
Education
Bachelor’s or Associate Degree/ Diploma in Medical Records Management or other Medical Records related discipline is required.
Experience Required
One (1) year of related experience with Bachelor’s Degree or three (3) years with Associate Degree/ Diploma is required.
Other Requirements(Certificates)
Completion of Hospital approved Coder Training Program is required.
Certified Coding Specialist (CCS) Certification is preferred.
