CODER, MEDICAL RECORDS

Summary

Reviews patient medical records for relevant diagnostic and procedure information and assigns corresponding codes according to standard coding guidelines maintaining productivity. Assists with the maintenance of various patient indexes and databases. Provides patient information retrieval assistance to researchers and others as needed.

Essential Responsibilities and Duties

• Researches medical records to develop complete codes for all diagnoses and procedures.
• Applies anatomy, physiology, disease process, and medical terminology knowledge to interpret the record and select accurate codes.
• Interprets and translates clinical documentation from the medical record into diagnostic and procedural codes; abstracts data into a computer database.
• Responsible for thoroughly knowing and utilizing all inpatient and outpatient coding systems according to the most recent rules, regulations, and conventions.
• Contacts physicians as necessary to request complete information and / or clarification to complete code the patient records.
• Maintains an accurate and timely computerized database utilizing prescribed abstract format.
• Maintains coding skills and professional credentials with appropriate continuing education by reading and applying coding materials and policies.
• Prepares or assists with preparing statistical or other special reports relating to patients, diseases, and treatments as needed.
• Performs audits and quality checks, provides training to trainees, and participates in Health Care Providers education as required.
• Keeps close communication and feedback loop with the clinical documentation team to improve documentation.
• Acts at all times as a service representative of the department. Provides cross-coverage for other positions in the department as requested by the management.
• Follows all Hospital’s related Policies and Procedures.
• Participates in self and others' education, training and development, as applicable.

Education

Bachelor’s or Associate Degree / Diploma in Health Information Management, Hospital Administration, Health Allied filed, or other related discipline is required.

Experience Required

One (1) year of related experience with Bachelor’s, or three (3) years of related experience with Associate Degree / Diploma is required.

Other Requirements (Certificates)

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