HIM Certified Coder Level 1

Description

Job Title: Medical Records Coder Level 1

Department: Health Information Management

Reports To: Director of HIM

FLSA Status: Non-Exempt

Hours: 40/week

Shift: Days, Monday - Friday

JOB DESCRIPTION

The Medical Records Coder Level 1 maintains a record of patient care by compiling, reviewing, and filing documentation of the patient’s condition, treatment, and health outcome. Codes ICD-10-CM, ICD-10-PCS, and CPT for all Inpatient, Emergency Room, and Outpatient records. The duties listed below are intended only as illustrations of the various types of work performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to this job.

• Maintains Health Information Management (HIM) Operations by following policies and procedures
• Maintains the Master Patient Index in conjunction with the other departments at Franklin County Medical Center (FCMC) through an Electronic Medical Records (EMR)
• Completes medical records by reviewing information, notifying healthcare providers of record deficiencies, tracking outstanding records, and getting signatures on records
• Maintains historical reference by abstracting and coding clinical data, such as diseases, operations, procedures, and therapies, using standard classification systems (SCS)
• Assigns diagnostic and procedural codes to all medical records using SCS
• Maintains patient confidence and protects hospital operations by releasing information to third-party payors, law firms, government agencies, and patients, following the release of information policies
• Assists nursing staff in the Quality Management activities by retrieving medical records for their review
• May fill in the role of transcription/editor
• Consults with the Director of HIM to ensure that all legal and regulatory requirements for the department are met
• Maintain confidentiality by protecting sensitive, proprietary, or confidential information. Adhere to HIPAA privacy and security requirements
• Protects patients and employees by adhering to infection-control policies and protocols
• Must wear Personal Protective Equipment (PPE) as required to maintain Infection Control Standards as set by the facility
• Performs other related duties as assigned

REQUIRED SKILLS/ABILITIES/COMPETENCIES

• Proficient in Microsoft Office Suite or related software
• Thorough understanding of education tracking practices and techniques
• Excellent leadership skills
• Ability to interact effectively with people who have widely differing backgrounds
• Excellent oral and written communication skills in English
• Attention to detail and follow-through on work tasks
• Ability to handle many tasks at one time
• Ability to develop and maintain relationships with vendors
• Excellent interpersonal and conflict resolution skills
• Excellent organizational skills and attention to detail
• Excellent time management skills
• Strong analytical and problem-solving skills
• Ability to prioritize educational courses
• Ability to act with integrity, professionalism, and confidentiality
• Proficiency with or the ability to quickly learn the organization's electronic medical record, medical equipment, and other technologies
• Proficiency in faxing, emailing, and Google Suite
• Ability to perform basic mathematical calculations, balance and reconcile figures, and perform some statistical analysis

Requirements

MINIMUM QUALIFICATION

• Must have a High School Degree or GED equivalent
• Certified Coding Associate (CCA), Certified Coding Specialist (CCS), or Certified Professional Coder (CPC) credentials required
• One year of medical coding experience is preferred

ESSENTIAL JOB FUNCTIONS

• Regular and predictable attendance
• Regularly required to sit, bend, stoop, and stretch
• Requires eye-hand coordination and manual dexterity sufficient to operate a keyboard, photocopier, telephone, calculator, and other office equipment
• Requires a normal range of hearing and eyesight to record, prepare, and communicate appropriate reports
• Frequently able to lift/carry up to 50 pounds
• This job's specific vision abilities include seeing and reading reports and data
• Prolonged periods sitting at a desk and working on a computer
• Must be able to access and navigate throughout the department within the organization's facilities
• Manual dexterity of hands and fingers to manipulate complex and delicate equipment with precision and accuracy. This includes frequent computer use and typing, accessing necessary information, emailing, and relocating educational equipment to classrooms, among other tasks

WORK ENVIRONMENT

• FCMC operates 24 hours a day, every day of the year. The operational needs of departments may require you to be available to work all shifts, including weekends and holidays, to meet the needs of patients.
• The employee generally works in typical office conditions, with a quiet noise level.
• Occasional exposure to emotional or physical stress.
• The employee works in the hospital setting.
• May be required to travel to other facilities to obtain training as necessary.