Medical Coder, Certified

Certified Medical Coder

The Certified Medical Coder codes medical records utilizing ICD-10-CM and CPT-4 coding conventions. Handles confidential patient medical records and abides by HIPAA. Reviews each medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges. This position will be coding for the hospital.

• Reviews the medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions for both inpatient and outpatient accounts.
• Sequences the diagnoses and procedures using current coding guidelines. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges.
• Consults with and educates physicians on coding practices and conventions in order to provide detailed coding information. Communicate with nursing and ancillary services personnel for needed documentation for accurate coding.
• Oversees the process of retrieving patient information and obtains all missing information in patient charts
• Gathers patient information in the allotted time frame
• Protects confidential medical information following HIPAA guidelines
• Maintains a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD- 10-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures.

• Maintains a thorough understanding of Health Information Management practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Health Care/Finance Administration (HCFA), etc
• Reviews and updates patients' charges on accounts when needed.
• Provides assistance and education to Hospital departments and clinics regarding coding matters.
• Assists Business Office staff with working billing edits, denials, and rebills.
• Works with Hospital departments on the selection of proper codes for prior authorizations needed in clinical areas such as Surgery, Case Management and Team Ortho.
• Assists in training new coders.
• Handles general clerical projects and requests
• Protects patient privacy and confidentiality in accordance with HIPAA and privacy laws.
• Ensures patient satisfaction, including troubleshooting when there is a complaint and developing process improvements to prevent reoccurrences.
• Demonstrates clear ownership of workplace and patient safety.
• Report mistakes, near misses, adverse events and quality and safety concerns.
• Participates in the development and implementation of safety and quality improvement activities.
• Other duties as may be assigned.

Job Requirements

Education:

Associates degree required or High School Diploma/GED. with 2-4 years' experience in medical coding in HIM department setting.

Licensure/Certification:
Certified Professional Coder (CPC) required. Certified Inpatient Coder (CIC) preferred.

Experience:

2-4 years coding experience in a hospital setting preferred; excellent customer service skills required; ability to work quickly and accurately with confidential information; advanced computer skills in Microsoft Word and Excel; above average typing and alpha numeric data entry skills.

Physical Requirements:

Frequent sitting and long periods of data entry. Occasional bending, stooping, and reaching. Occasionally lift 25 lbs.