Coder Health Information Management Technician

About This Role

This Health Information Management Coder/Technician II role is responsible for ensuring patient record documentation meets state and federal regulations and that physician documentation supports coding. The position involves applying official coding guidelines for diagnostic and procedure codes for both inpatient and outpatient accounts, and assisting the HIM Manager with daily departmental activities.

Responsibilities

• Ensure patient record documentation meets state and federal regulations for content, completeness, and timeliness
• Code ED, Outpatient, and Inpatient accounts correctly to ensure coding guidelines are followed for appropriate reimbursement, utilizing Alpha II coder, Code Correct, and AMA IC.S-10-CM, and HCPCS coding books
• Accurately complete chart review to ensure accuracy and completeness for analytical, statistical, and patient care purposes
• Call physicians and ancillary departments to get correct diagnosis to complete coding procedures
• Physically locate and wait for physicians, nursing staff, and therapists to obtain correct diagnosis to complete coding procedures
• Assure timely completion of chart deficiencies by promptly recording such deficiencies in the ICR desktop and by providing healthcare staff with the information they require to complete the deficiencies
• Receive calls from ancillary departments, physician offices, etc. to get correct ICD-10 and CPT coding
• Transcribe "STAT" dictations as a priority and other transcription as needed
• Refer inconsistent or incorrect coding by provider to management when a trend or pattern is identified
• Respond to and process all requests for copies of medical records from other healthcare facilities, over the phone, and walk-in requests, ensuring correct requests are filled out properly
• Establish and maintain healthy interpersonal relationships with all staff members
• Recognize the important part this position plays in Performance Improvement of the ongoing delivery of patient care
• React properly and follow correct policy and procedure in an emergency and/or disaster
• Wear Personal Protective Equipment (PPE) as situations require, maintaining Infection Control standards set by hospital

Requirements

• High School Diploma
• CCS coding certification from AAPC or AHIMA, or accredited college, or a minimum of 5 years of applicable ICD diagnostic, CPT procedural, and HCPCS coding in a hospital or diverse specialty physicians office
• Experience interpreting a variety of instructions in written, oral, diagram, or schedule form
• Advanced knowledge of Medical Terminology
• Excellent interpersonal and communication skills, both written and oral
• Previous experience capturing data and analyzing quality measures, case mix index, and health record documentation compliance