Clinic Coder

Job Title:         Coder                  

Department:  Health Information Management (HIM)

Reports to:     HIM Manager              

FLSA Status:    Non-Exempt

Overall Responsibility:

The Coder, under the general direction of the Manager of HIM, is primarily responsible for reviewing medical record documentation and assigning accurate diagnosis and procedure codes.  Performs analysis of medical records.  Audits medical records for completeness and proper documentation.  Assists business office with coding issues.

Key tasks and responsibilities

 Essential functions:

• Codes and abstracts medical records using ICD-10-CM and ICD-10-PCS and CPT codes.
• Assists Billers regarding coding issues and questions.
• Assists with responses to KFMC (the QIO) and other review organizations.
• Communicates routinely with physicians about diagnoses, procedures, and documentation.
• Queries physicians and other healthcare providers when code assignments are not straightforward or documentation is inadequate, ambiguous, or unclear for coding and legal health purposes.
• Audits medical records for completeness and accurate information.
• Maintains knowledge of current state and federal coding guidelines.
• Analyzes records for physician deficiencies and enters/removes deficiencies in EMR.
• Answers telephone inquiries.
• Copies and faxes records as needed.
• Monitors unbilled records report.
• Maintains established hospital and departmental policies and procedures.
• Maintains confidentiality of patient and hospital related business.
• Develops and maintains an effective working relationship with other hospital employees.
• Documents concisely, precisely and accurately on records or documents as indicated by policy.
• Participates in Quality Assessment activities as directed for the continuous improvement of patient care and hospital business.

Non-Essential functions:

•  Performs other duties as assigned.
• Actively supports and upholds the mission and core values of the Hospital.
• Remains knowledgeable of and follows the policies of the Hospital.
• Always maintains patient and hospital confidentiality.
• Keeps Manager apprised of day-to-day situations.
• Actively protects patients and self by following OSHA and other standards reviewed in annual training.
• Performs medical staff services functions in the absence of the Manager, Health Information Management’s absence.

Licensure and Certification: 

• Registered Health Information Technician (RHIT) or
• Registered Health Information Administrator (RHIA) or
• Certified Coding Specialist (CCS or CCS-P) or
• Certified Professional Coder (CPC)

Experience Required: 

• Two years’ coding experience required.

Environmental and physical requirements: 

• Candidate must be able to read and speak English fluently, have cognitive skills for math, reading, computer skills, communication skills to deal well with the public (customers), physicians, and other hospital employees. 
• Vision for near, mid-range, far and accommodation. 
• Hearing for low, medium, and high pitch.  Job requires sitting for 100% of activities with minimal up and down activity. 
• Job risk includes exposure to computers for 8 hours per day with typing activities, lifting of 20-30 pounds maximum.

Equal Employment Opportunity (EEO) & Americans with Disabilities Act (ADA) Statement:

Our hospital is committed to fostering an inclusive and diverse workplace. We provide equal employment opportunities to all employees and applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other characteristic protected by applicable law. Additionally, we provide reasonable accommodation for qualified individuals with disabilities in the application and employment process. If you require assistance or accommodation due to a disability, please contact Human Resources so that we may engage in an interactive process to determine appropriate accommodation.