Medical Coder
Department: Health Information Management Position: Full Time, Non-Exempt
Brief Description of Job:
Assembles, analyzes, codes, abstracts, reports, maintains and extracts medical records information.
Organizes and checks medical records for completeness, accuracy and compliance with regulatory
requirements.
Assist HIM Record Specialist as needed for scanning, record releases and other duties.
Essential Functions:
- Apply ICD-10-CM, CPT and HCPCS standardized codes to patient records. Enter data with 3M
Encoder software.
- Responds to requests for patient records from physician offices, hospitals, patients Performs
qualitative analysis to ensure accuracy, internal consistency and correlation of recorded data on
an as needed basis.
- Utilizes professional and tactful communication skills to enhance teamwork with all departments
and divisions of the organization.
- Participates in staff development activities and orientation as requested.
- Performs quality improvement activities in support of institution wide medical documentation
concerns.
- Demonstrates a current level of knowledge of various payor regulations by functioning within
those guidelines.
- Coordinates with Business Office and Mount Ayr Medical Clinic regarding charge entry, medical
necessity and coding/billing issues.
- Demonstrates ability to transcribe complete and accurate medical documentation in accordance
with medical terminology and body systems.
- Operates transcription equipment as directed to complete assignments.
- Participate in training for CEU’s to keep certifications current for the position.
- Works assigned shift/shifts, weekends and holidays, as scheduled.
- Codes disease and injury diagnoses, acuity of care and procedures, using standard references for
coding to include current ICD, CPT, HCPCS, Physician Desk Reference and other authoritative
sources.
- Contacts appropriate medical staff members to rectify inconsistencies, deficiencies and
discrepancies in medical documentation, code assignment or charges.
- Provides assistance to the medical staff by researching reference materials as requested related to
coding, documentation and charge practices.
- Participates in other quality improvement activities as requested.
- Miscellaneous office duties, i.e., filing and/or retrieving medical records.
Educational/Experience Requirements:
- High School Diploma or equivalent.
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