Medical Coder

Replies within 24 hours Position Summary The Medical Coder is responsible for accurate coding of all clinical, inpatient, outpatient, and emergency service diagnoses and conditions, working from the appropriate documentation in the health record of the patient. Classification systems include ICD-10-CM, ICD-10-PCS and CPT-4 as well as other specialty systems as required by diagnostic category. All work performed in accordance with the department’s approved policies and procedures. Also carries out routine clerical work in answering telephones, providing customer assistance when needed. The

job description
is a guideline only and may not incorporate all functions of the job; education and experience outlines are ideal qualifications/assets but do not necessarily reflect the requirements of the position. Essential Job Functions include the following, but are not limited to:
• Adheres with all hospital policies and procedures and follows supervisor/manager directions.
• Codes all diagnoses, treatments, and procedures according to the appropriate system for the category of patient encounter.
• Completes the coding with a minimal number of discrepancies.
• Assists physicians and other direct patient care professional in questions regarding level of detail for diagnostic entries, according to the organization’s guidelines.
• Prepares workload reports and participates in department’s total quality management studies.
• Promotes public relations through prompt and courteous service.
• Fosters respect for patient privacy by maintaining confidentiality in all phases of the work.
• Scans patient health information to medical record encounter for completion of chart.
• Ensures that Supervisor is fully informed of work status.
• Reports any problems or changes in work schedule to Medical Records Director. Knowledge, Skills, And Abilities 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. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Problem solving—the individual identifies and resolves problems in a timely manner, gathers and analyzes information skillfully.
• Customer service—the individual manages difficult client/customer situations, responds promptly to customer needs, solicits customer feedback to improve service, responds to requests for service and assistance and meets commitments.
• Planning/organizing—the individual prioritizes and plans work activities and uses time efficiently.
• Quality control—the individual demonstrates accuracy and thoroughness, monitors own work to ensure quality and applies feedback to improve performance.
• Quantity—meets productivity standards and completes work in a timely manner.
• Adaptability—the individual adapts to changes in the work environment, manages competing demands and is able to deal with frequent change, delays or unexpected events. Being flexible to work on weekends and at nights.
• Dependability—the individual is consistently at work and on time, follows instructions, responds to management direction and solicits feedback to improve performance.
• Safety and security—the individual observes safety and security procedures and uses equipment and materials properly. CORE VALUES
• Integrity – Accepts accountability for problems and errors without excuses or blaming others Truthful in all dealings and communications, internally and externally. Fair with employees, customers, suppliers and investors.
• Respectfulness – Treats everyone with respect and courtesy; value the unique qualities and needs of individuals and committed to understanding and appreciating the diversity of cultures, opinions, and experiences of others.
• Teamwork – Works effectively with co-workers as a team; mentor and provide technical knowledge to co-workers; and demonstrate good attendance.
• Accountability – Makes all patients and customers a priority and attend to their needs immediately
• Professionalism – Knows how to perform your job, demonstrates a willingness to learn, demonstrates effective interpersonal interactions Qualifications Education and/or Experience High school diploma or the equivalent.
• Accredited record technician, registered record administration, and/or coder specialist, possess equivalent training in coding systems, advanced medical anatomical terminology, clinical medicine theory, and reimbursement principles.
• Knowledge of medical terminology/anatomy.
• Knowledge of health record content and sequence.
• Knowledge of coding software.
• Knowledge of coding/classification systems appropriate for inpatient, outpatient, and emergency care.
• Skill in answering a telephone in a pleasant and helpful manner.
• Ability to read, understand and follow oral and written instructions.
• Ability to establish and maintain effective working relationships with patients, employees and the public.
• Must be well organized and detail-oriented. Language Skills Reads and comprehends instructions, light correspondence, and memos; Writes simple to complex correspondence; Presents information in one-on-one and small group situations to customers, clients, and other employees effectively. Mathematical Skills Adds, subtracts, multiplies, and divides in all units of measure using whole numbers, common fractions, and decimals. Reasoning Ability Applies common sense understanding to carry out detailed, written or oral instructions; Deals with problems involving some variables in standardized situations.