CODER

Summary Abstract clinical information from medical records and code all disease entities, symptoms and procedures as necessary on acute and outpatient records.

ESSENTIAL DUTIES AND RESPONSIBILITIES

include the following. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and /or ability required. Identify and assign

ICD-9 CM

principal and secondary diagnoses and ICD-9 CM and CPT procedure codes in accordance with coding and reimbursement guidelines, including correct coding initiative. Maintain a minimum accuracy rate consistent with CMS regulations and internal reimbursement expectations. Assist the business office in clarification of coding versus reimbursement issues. Participate in coding meetings and educational conferences to maintain coding accuracy. Ensure confidentiality of patient information. Assist with trauma registry abstraction. Assist with utilization review. Assist in educating hospital personnel, patients and other health care providers of the policies and procedures related to coding process. Use department computers in an appropriate efficient manner. Assist with gathering information for ER peer review. Assist in remaining compliant with EMTALA paperwork. Participate in quarterly QM projects as assigned by HIM Manager or Director. Assist in developing and maintaining policies and procedures as assigned by the HIM Manager. Assist in filing all medical records. Assist all departments throughout Saunders Medical Center to locate needed reports and records. Destroy all inpatient and outpatient records according to policy and state and federal regulations. Assist in maintaining all file areas in an orderly fashion. Participate in all quality, safety, security and infection control programs that are mandatory as well as those required and provided by the department. Uphold confidentiality and HIPAA compliance at all times and report violations to the Privacy Officer. Understand and comply with the requirements of the Saunders Medical Center's Compliance Program, including, but not limited to the Code of Conduct, the Compliance Policy, all Saunders Medical Center-wide policies for compliance, and compliance plans affecting specific duties and responsibilities. Participate in all education and training programs regarding compliance as required by Saunders Medical Center policy and as requested by the Manager. Demonstrate personal traits of a high-level commitment, motivation and energy; team orientation; professionalism; trust; personal honesty and integrity; and a demonstration of placing others in a place of high value and treating them with dignity and respect. Other duties as assigned by the Manager. Supervisory Responsibilities This position has no supervisory responsibility. Disclosure Statement The above statements reflect the general details considered necessary to describe the essential functions of the job as identified, and shall not be considered as a detailed description of all work requirements that may be inherent in the position. Education and/or Experience High school diploma or equivalent. Associate degree in HIM preferred. Basic knowledge of computer and standard office equipment. Experience in medical terminology, transcription, ICD-9 CM and CPT coding. Knowledge of human anatomy and physiology. Certificates Licenses, Registrations RHIT, RHIA, CCS, CPC, and CPC-H preferred. Language Skills Must be able to read, write and follow written and oral instructions and possess positive skills in communication. Ability to deal tactfully with personnel, patients, visitors, and the general public. Mathematical Skills Ability to calculate at the level necessary to perform essential duties of the position. Reasoning Ability Ability to make independent decisions when circumstances warrant such action. Ability to interpret a variety of instructions furnished in oral, written, diagram or schedule form. Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee must sit frequently and spend long periods of time examining documents. The employee must stand, reach with arms and hands and occasionally lift, push or pull XX pounds. The employee must occasionally walk and climb or balance. Work EnvironmentCopy Link The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position. Attendance is essential and required for a successful working environment.