HIM Medical Records Coder (CERT)

PRIMARY RESPONSIBILITIES

• Coding Inpatient Medical Records
• Accurately codes principle diagnosis from information from inpatient medical records, utilizing ICD-10-CM classification system.
• Accurately codes PSYCHIATRIC/MEDICAL diagnoses from information from inpatient medical records, utilizing ICD-10-CM classification system.
• Accurately codes PSYCHOSOCIAL/ENVIRONMENTAL diagnoses from information from inpatient medical records, utilizing ICD-10-CM classification system.

• Coding Outpatient Medical Records
• Accurately codes principle diagnosis from information from outpatient medical records, utilizing ICD-10-CM classification system.
• Accurately codes PSYCHIATRIC/MEDICAL diagnoses from information from outpatient medical records, utilizing ICD-10-CM classification system.
• Accurately codes PSYCHOSOCIAL/ENVIRONMENTAL diagnoses from information from outpatient medical records, utilizing ICD-10-CM classification system.

• General Coding of Medical Records
• Contacts attending physicians regarding questions on diagnoses needed for greater detail or different terminology in order to assign accurate codes to medical records.
• Accurately enters code alpha/numbers of diagnoses into the computer system.
• Ensures all diagnoses are sequenced properly.

• Abstracting
• Accurately abstracts data from discharged inpatient records and enters them into computer system.
• Ensures OSHPD data is correct.
• Accurately assigns attending physician.
• Accurately assigns referring physician.
• Accurately assigns consulting physician(s).

• Reimbursement
• Insures that all factors necessary for assigning an accurate DRG (Diagnostic Related Groups) are present.
• Manages work flow so that bills are dropped by the third business day.
• Manages work flow so that specific insurance requirements are met.
• Works with physicians so that diagnoses are present upon discharge.
• Works with Business Office to assist with payment issues.

• General
• Provides information and responds to inquiries regarding medical documentation and DRGs to hospital staff.
• Generates computer reports from abstracted data.
• Participates in other HIM functions, as assigned.

Note: The essential job functions of this position are not limited to the duties listed above.

KNOWLEDGE, SKILLS, AND ABILITIES

THIS SECTION DESCRIBES WHAT KNOWLEDGE, SKILLS AND MENTAL APTITUDE AN EMPLOYEE IN THIS POSITION SHOULD CURRENTLY POSSESS. THIS LIST MAY NOT BE COMPLETE FOR ALL KNOWLEDGE, SKILLS AND MENTAL APTITUDE REQUIRED FOR THIS POSITION.

1. Ability to work with a high degree of precision, paying attention to detail in order to achieve the high levels of accuracy required.
2. Ability to adhere to ethical principles relating to quality, truth, and accuracy in work performance and productivity.
3. Ability to organize, collect and classify diagnostic information for hospital reimbursement purposes.
4. Thorough knowledge of medical terminology.
5. Knowledge of the International Classification of Diseases (ICD-10-CM) codes; knowledge of DSM V Diagnostic Manual of Mental Disorders.
6. Ability to communicate effectively both orally and in writing.
7. Ability to be thorough.
8. Possesses sound judgment; discretion; and initiative.
9. Ability to organize and set workload priorities to meet deadlines.
10. Thorough understanding of the content of the medical record as well as clinical knowledge including extensive training in anatomy, physiology, pharmacology, and clinical disease process.
11. Ability to assess the medical record content and highlight shortcomings to management.
12. Ability to maintain ICD-10-CM coding books to make sure they are updated to the current version being used.
13. Ability to assist with the education of clinical staff with regard to ICD-10-CM and documentation requirements.
14. Ability to liaison with computing and finance staff.
15. Ability to adhere to safety policies and procedures.
16. Ability to work as a team player.
17. Ability to demonstrate resourcefulness, patience and dedication.
18. Ability to accept direction and adhere to policies and procedures.
19. Ability to recognize the importance of adapting to the various patient age groups (adolescent, adult and geriatric).
20. Ability to work in a fast-paced environment.
21. Ability to react calmly and effectively in emergency situations.
22. Ability to continually update skills and knowledge.

PHYSICAL, MENTAL, AND SPECIAL DEMANDS

THIS SECTION DESCRIBES HOW AN EMPLOYEE IN THIS POSITION CURRENTLY PERFORMS THE FUNCTIONS OF THIS POSITION. MODIFICATIONS TO THE MANNER IN WHICH THIS JOB MAY BE PERFORMED WILL BE REVIEWED ON A CASE BY CASE BASIS.

1. Ability to sit for long periods, up to 8 hours.
2. Ability to use both hands in fine manipulation of small tools (e.g., copier, computer keyboard, telephone).
3. Ability to push and pull up to 10 lbs. (file cabinet drawers, computer paper boxes).
4. Ability to see well enough to read handwritten and typewritten material.
5. Ability to stoop, kneel, and bend daily to retrieve files from bottom shelves.
6. Ability to move flexibly is required in filing and retrieving medical records.
7. Ability to reach, turn, and twist above and below the waist daily to retrieve files from top shelves to get office supplies from upper shelves in supply closet.
8. Ability to spend 90% of working time in an environment of continuous low voices and office machine noise typical for business office atmosphere.
9. Attend all mandatory facility in-services and staff development activities as scheduled.

MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES:

THIS SECTION DESCRIBES THOSE MACHINES, TOOLS, EQUIPMENT, AND OTHER WORK AIDES AN EMPLOYEE IN THIS POSITION MUST BE ABLE TO USE.

2. Computer and various software programs.
3. Copy machine.
4. Policies, procedures, plans and program manuals.
5. ICD-10-CM, DSM V and related reference books.