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Certified Medical Coder

3 months ago

Rapid City, United States Great Plains Tribal Leaders Health Board Inc Full time
Job DescriptionJob Description

Job Summary:

Primary responsibilities of the certified medical coder duties in support of the Oyate Health Center (OHC) Patient Accounts Department, facilitating and is responsible for converting medical diagnosis, supplies and processes into standardized codes that are used when filing insurance claims, to ensure compliance with Medicare, Medicaid, and private insurance rules and regulations.

Essential Functions:

  • Knowledge of Health Insurance Portability and Accountability Act (HIPAA) and Health Information Technology for Economic and Clinical Health Act (HITECH).
  • Knowledge of medical records requirements and functions.
  • Knowledge of ICD-10 (International Classification of Diseases), CPT 4 (Current Procedural Technology) and HCPCS (Healthcare Common Procedure Coding System) coding guidelines.
  • Analyzes and abstracts all necessary information from the record to reflect secondary complications and co-morbidity conditions.
  • Codes diagnosis and/or procedures from the medical records, and assures the final diagnosis and procedures as stated by the medical provider are valid and complete.
  • Codes complex and difficult records accurately; makes complete and accurate selection of the principal diagnosis and principal procedure/operation; diagnosis codes are sequenced properly; and assures that all orders (medication, lab, and radiology) have been documented properly to support level of services and reflect the medical necessity for the order.
  • Assures the presence of all components of the record, including correct identification, health record number, signatures, dates, accurate and complete notes (chief complaint, history of present illness (HPI), review of systems, examination, and assessment and plan are completely documented.
  • Analyzes and abstracts all necessary information from the record to reflect secondary complications and co-morbidity conditions.
  • Codes diagnosis and/or procedures from the medical records, and assures the final diagnosis and procedures as stated by the medical provider are valid and complete.
  • Codes complex and difficult records accurately; makes complete and accurate selection of the principal diagnosis and principal procedure/operation; diagnosis codes are sequenced properly; and assures that all orders (medication, lab, and radiology) have been documented properly to support level of services and reflect the medical necessity for the order.
  • Assures the presence of all components of the record, including correct identification, health record number, signatures, dates, accurate and complete notes (chief complaint, history of present illness (HPI), review of systems, examination, and assessment and plan are completely documented.
  • Examines the level of services to ensure it is accurate and appropriate for the documentation in the note and when appropriate modify level of service.
  • Completes medical record by reviewing information; notifying health care providers of record deficiencies; tracking outstanding records; and resolves medical record discrepancies by collecting and analyzing information.
  • Incumbent works independently. Takes the initiative to communicate with Providers and Billing staff on coding/documentation issues.
  • Participates on performance improvement teams and other committees as assigned.
  • Must comply with federal laws and regulations as required by the Health Insurance Portability and Accountability Act (HIPAA).
  • Performs related duties.

Professional Behavior

  • Effectively plan, organize workload, and schedule time to meet the demands of the position.
  • Work in a cooperative and professional manner with OHC and GPTCHB staff.
  • Treat Great Plains tribes and collaborators with dignity and respect.
  • Utilize effective verbal and written communication skills.
  • Advance personal educational development by attending training sessions and seminars as appropriate.
  • Exemplify excellent customer service with tribal stakeholders, health board colleagues, program partners, service recipients, visitors, and guests.
  • Foster a work environment of wellness, courtesy, friendliness, helpfulness, and respect.
  • Relate well and work collaboratively with coworkers and all levels of staff in a professional manner.
  • Consistently demonstrate respect for and acceptance of differing capabilities, cultures, gender, age, sexual orientation and/or personalities.
  • Maintain and ensure organizational privacy and confidentiality.
  • Handle crisis and tolerate stress professionally.
  • Be self-directed and take proactive initiative to assist others.
  • Resolve issues with other departments and coworkers without direct supervision if needed.
  • Exercise flexibility to alter plans/routines when situations require and continue to perform without projecting stress/frustration that would adversely affect the work environment.
  • Promote an alcohol, tobacco, and drug-free lifestyle.
  • Embrace modes of appearance and attire that reflect a professional presence.
  • Adhere to GPTLHB policies and procedures.
  • Other duties as assigned by the Supervisor

Requirements

  • Participates in Core Connections training and applies GPTLHB Core Connections concepts and practices in their work.
  • Knowledge of federal, state, and local regulations affecting areas of responsibility.
  • Knowledge of occupational health, safety and environmental compliance program management principles.
  • Knowledge of industrial hygiene, environmental and safety engineering, and fire protection.
  • Knowledge of local, state and federal occupational safety and health regulations.
  • Knowledge of job hazard analysis and other analytical techniques.
  • Knowledge of accident prevention principles.
  • Knowledge of safety inspection principles.
  • Knowledge of computers and job-related software programs.
  • Skill in decision-making and problem-solving.
  • Skill in managing multiple projects.
  • Skills in oral and written communication.
  • Skill in prioritizing and planning.
  • Skill in interpersonal relations.
  • Skill in the use of such office equipment as a computer, scanner, fax machine, and copier.

Supervisory Controls

The work is closely controlled through the structured nature of the work itself, the circumstances in which it is performed, or by the supervisor through review of the work.

The supervisor assigns specific tasks (one-of-a-kind and repetitive) and provides clear, detailed, and specific instructions. The employee works as instructed and consults with the supervisor as needed on all matters not specifically covered in the original instructions or guidelines.

The supervisor reviews the work by checking progress or reviewing completed work for accuracy.

Guidelines

Very specific, detailed guidelines covering all important aspects of the assignment, including instructions on how to complete the assignment, are provided to the employee. The employee works in strict adherence to the guidelines; any deviations must be authorized by the supervisor.

Complexity/Scope of Work

The work consists of related steps, processes, or methods. The decision regarding what needs to be done involves various choices that require the employee to recognize the existence of and differences among a few easily recognizable situations. Actions to be taken or responses to be made differ in such things as the source of information, the kind of transactions or entries, or other differences of a factual nature.

The work involves the execution of specific rules, regulations, or procedures and typically comprises a complete segment of an assignment or project of broader scope. The work product or service affects the accuracy, reliability, or acceptability of further processes, services, and/or patient care.

Personal Contacts

The personal contacts are with employees within the department, office, project, or work unit, and in related or support units. The contacts are with other employees, patients and other customers, and members of the general public in very highly structured situations. The purpose of the contact and the question of with whom to deal are relatively clear.

Purpose of Contacts

The purpose is to obtain, clarify, or give facts or information regardless of the nature of those facts; i.e., the facts or information may range from easily understood to highly technical.

Work Environment/Physical Demands

The work involves moderate risks or discomforts that require special safety precautions, e.g., working around moving parts, carts, or machines; exposure to contagious diseases or irritant chemicals. Employees may be required to use protective clothing or gear, such as masks, gowns, coats, boots, goggles, gloves, or shields.

The work requires some physical exertion, such as long periods of standing; walking over rough, uneven, or rocky surfaces; recurring bending, crouching, stooping, stretching, reaching, or similar activities; or recurring lifting of moderately heavy items. The work may require specific, but common, physical characteristics and abilities, such as above average agility and dexterity. The employee must be able to read, write, speak and hear.

Supervisory and Management Responsibility

This position has no formally assigned supervisory responsibility or authority. The employee is responsible only for the performance of their own assigned work. They may be asked to train new employees in the fundamentals of the jobs or to participate in cross‑training of other employees in the department, but such assignments do not include the on‑going authority to assign and review work of other employees or to recommend or take corrective action with regard to other employees' performance.

Minimum Qualifications

Education/Relevant Experience: Completion of a formal training program or an associate’s degree and one (1) year of relevant experience; or a high school diploma or GED and three (3) years of relevant experience.

Certification: Certified Medical Coding Certification

Individuals must have applicable education or experience applying a body of standardized rules, procedures, or operations to perform the full range of standard clerical assignments and resolve recurring problems or to operate and adjust varied equipment for purposes such as performing numerous standardized tests or operations.

The GPTLHB is a tribal organization that follows tribal preference laws. Our policy is to give preference to qualified Indian/Tribal candidates overqualified non-native candidates in hiring decisions if all other qualifications are equal.

Employment is contingent upon the outcome of all required criminal background checks and pre-employment drug screen.