Health Information Coder

Job Summary:

Interprets and translates into codes Diagnosis by physicians and other healthcare professionals regarding patient diagnoses, diagnostic procedures, therapeutic procedures, clinical course, in order to accurately document patient’s reason for care and to facilitate quick and accurate reimbursement of healthcare services.

Primary Job Responsibilities:

1. Codes/abstracts/analyzes medical diagnoses to provide a permanent classification record of patient care, following coding guidelines of AHIMA, Medicare/Medicaid and other third party payers.
2. Codes all diagnostic and operative information from the medical record using ICD 10 CM/PCS, CPT and HCPCS coding classification systems and independently quality checks own work.
3. Optimizes hospital payment legitimately and ethically by utilizing approved coding guidelines and conventions.
4. Ensures that all data abstracted is consistent with guidelines outlined by JC, IDPH and CMS, regional and local policy.
5. Meets established quality and productivity standards and deadlines.
6. Demonstrates an understanding of the medicolegal implications and responsibilities related to the coding of patient records to protect the patient and the business/institution.
7. Operates designated computer terminal, coding equipment and software programs (3M, CPSI, eMD’s) as directed to complete assignments.
8. Follows policies and procedures to contribute to the efficiency of the coding/abstracting area of the department.
9. Expands job related knowledge skills to improve performance, adjust to change, keep up on revisions of coding and medical necessity.
10. Uses interpersonal skills effectively to build and maintain cooperative working relationships.
11. Performs other duties as assigned by the Health Information Management Director.
12. Conducts good telephone etiquette at all times.
13. Exhibits professionalism in personal appearance and conduct. Adheres to dress code, work schedules and other personal policies.
14. Provide reports as requested on coding and billing.

Schedule: Mon & Wed – 8:00a to 4:30p

Required Qualifications

1. Minimum education level of registered health information technician (RHIT) or certified coding specialist (CCS) status, or equivalent of two years work experience in medical records or physician’s office and continuing education in the coding area.
2. Knowledge of medical terminology, anatomy, physiology, clinical medicine and various medical specialties.
3. Knowledge of ICD 9 CM/PCS, ICD 10 CM/PCS, CPT, HCPCS coding guidelines and practices.
4. Excellent oral communication skills, including English usage and grammar to communicate with physicians and their office personnel regarding diagnoses, as well as persons of all ages and nationalities.
5. Ability to use designated reference materials.
6. Ability to operate designated word processing, computer terminals, software and other equipment as specified.