Health Information Coder (Santa Rosa)

POSITION TITLE: Coder

REPORTS TO (TITLE): Director of Health Information Management

DESCRIPTION OF POSITION:

Organize and manage Health Information ensuring quality, accuracy and timely accessibility of patient medical information. Process transcription reports for patient records and complete correspondence reports. Perform qualitative and quantitative chart analysis and validate admission/discharge census. Maintain security and privacy of patient records and provide support to physicians and other disciplines within the organization.

KEY RESPONSIBILITIES:

• Has experience in using computer, Excel program and good typing skills.
• Proficient in English language with at least good comprehension of the English language.
• Does the accurate abstracting of patient’s information, and enters accurate discharge disposition of patients in AIS.
• Assigns/supplies correct ICD-10-CM and CPT, if asked, on all diagnoses provided in all patients’ charts.
• May be asked to supply HCPCS CODES on all procedures and services performed.
• Queries physicians to verify correct diagnosis.
• Attends seminars or webinars as required to remain current on coding issues.
• Audits medical records to ensure proper coding completed and to ensure compliance with both federal and state regulatory bodies.
• Accurately follows coding guidelines and legal requirements to ensure compliance with both federal and state regulatory bodies.
• Monitors the daily Missing Discharge DX Report from AIS.
• Makes sure that all discharged charts are coded no more than 3 days after discharged.
• Reports all cases with undetermined or missing primary diagnoses to the HIM Director.
• Coordinates and pull charts necessary for coding audits including Medicare coding audits.
• Arranges coverage when planning out of town leave.
• Maintains current Coding certification if any.
• Works well and harmoniously with the rest of the HIM Staff.
• Keeps good work ethics.
• May help in gathering discharge charts when asked.
• May answer incoming calls when asked.
• Maintains punctual work attendance and has flexibility in schedule and may be asked to flex when there are few charts to code.
• Maintains confidentiality of her/his assigned ASR’s system username and password.
• Adheres to HIPAA law.

Requirements

Knowledge and Experience:

• High school diploma or equivalent.
• CCS AHIMA Certification preferred.
• Current NCI equivalent as approved by the Chief Nursing Officer (or obtained within the first 30 days of hire).
• One year of experience working with medical records preferred.
• Coursework specific to regulations pertaining to proper administration of medical records preferred.
• Demonstrated knowledge of patient privacy relative to maintaining medical records required.
• Familiarity with medical terminology preferred.

Skills and Abilities:

• Maintains confidentiality of patients at all times
• Sensitivity to and willingness to interact with persons of various social, cultural, economic and educational backgrounds.
• Proficiency with software and/or equipment (Microsoft Office applications including Outlook, Word, Excel and PowerPoint.)
• Strong organizational skills with ability to prioritize projects, work relatively independently, manage multiple tasks, and meet deadlines.
• Strong written and verbal communication skills.
• Strong interpersonal skills. Ability to work with people with a variety of background and educational levels.
• Ability to work independently and as part of a team.
• Good judgment, problem solving and decision-making skills.
• Demonstrated commitment to working collaboratively as well as possessing the skills to lead, influence, and motivate others.
• Ability to work in a fast-paced, expanding organization.

Physical Requirements:

While performing the duties of this job, this position is frequently required to do the following:

• Use standard office equipment and access, input, and retrieve information from a computer. Use computer keyboard with manual and finger dexterity and wrist-finger speed sufficient to perform repetitive actions efficiently for extended periods of time.
• Communicate effectively in person or via telephone in a manner which can be understood by those with whom the person is speaking, including a diverse population.
• Frequent bending, squatting, kneeling, climbing with the use of a step stool and twisting. Lift and carry up to 20 pounds.
• Sit or stand for minimum periods of one hour at a time. Come and go from the work area repeatedly throughout the day.
• Give and follow verbal and written instructions with attention to detail and accuracy.
• Perform complex mental functions and basic arithmetic functions; interpret complex laws, regulations, and policies; collect, interpret, and/or analyze complex data and information.
• Vision: see details of objects at close range.
• Coordinate multiple tasks simultaneously.

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Benefits

• Medical
• Vision
• Dental
• 401(k)
• 3.5 Weeks Paid Time Off
• $25,000 Life insurance policy is provided at no charge to the employee