Coder, Medical Billing and Coding, Medical Records

WOOSTER COMMUNITY HOSPITAL JOB DESCRIPTION Coder

MAIN FUNCTION:
The Coder is responsible to review, abstract, assign appropriate ICD
10-CM, CPT and DRG codes as needed to all patient charts/accounts. Assists the revenue cycle team by performing audits to detect, assess and resolve reimbursement and revenue compliance concerns. Involved in the charge capture process.

RESPONSIBLE TO:
System Director of Revenue Cycle

• Previous coding experience / knowledge.
• Ability to follow written and verbal directions.
• Knowledge of state and federal coding regulations.
• Knowledge of Anatomy, Physiology, Disease Processes, and Medical Terminology.
• RHIT/RHIA/CCS/ or CCA eligible.
• If not credentialed at time of hire, then applicant must become credentialed in one of the four areas within 12 months of hire to remain employed.
• Ability to operate computer on a daily basis and perform basic office procedures.
• No written disciplinary action within the last 12 months.

• * Denotes ADA Essential
• * Follows Appropriate Service Standards
• Completion of an accredited program in Health Information Technology.

• * Reviews charts of all inpatient, outpatient surgeries, observations, clinic, special procedures, emergency room records, and outpatient testing or treatment room records, etc. on a daily basis in order to assign proper ICD
  10-CM and/or CPT codes for billing and statistical reports.
• * Utilizes encoder software to code and finalize bill
• * Able to prioritize most needed coding and code in a timely manner.
• * Abstracts demographic information as needed.
• * Works with Manager with problem accounts. Tracks down these accounts and works with the physician to complete these records and codes them for billing.
• * Reports any problems in coding, billing or registrations to the Manager.
• * Ensures that chart information supports the diagnosis and treatment. Charts must be thoroughly reviewed and discrepancies communicated to the physician for correction or further documentation.
• * Performs audits of revenue cycle processes utilizing reports from various software applications (i.e. Craneware, Meditech, Quadex, etc.) and report findings to the Manager.
• * Must be able to perform audits utilizing all source documents, including the medical record, itemized charges, UB92 and charging worksheets.
• * Performs revenue audits for clinical departments on a rotating basis as well as requested audits on an as needed basis. The need for an audit can be identified by PFS, HIM or clinical departments.
• * Performs charge capture processes for the specified categories of charges.

4/95 Revised Dates: 3/00, 6/00, 3/02, 9/03, 1/04, 3/05, 5/09, 11/10, 10/15, 2/20

Approved by Human Resources:

Monday thru Friday

40

FTE per week