Reviews patient medical records for relevant diagnostic and procedure
information and assigns corresponding codes according to standard coding
guidelines maintaining productivity. Assists with the maintenance of various
patient indexes and databases. Provides patient information retrieval
assistance to researchers and others as needed.
Essential Responsibilities and Duties**
1. Researches medical record to develop the most complete codes for all
diagnoses and procedures.
2. Applies knowledge of anatomy, physiology, disease process and medical
terminology to interpret the record and select accurate codes.
3. Interprets and translates clinical documentation from the medical record
into diagnostic and procedural codes; abstracts data into computer data base.
4. Responsible for thoroughly knowing and utilizing all coding systems both
inpatient and outpatient according to the most recent rules, regulations and
conventions.
5. Contacts physicians as necessary to request more complete information
and/or clarification in order to completely code the patient records.
6. Maintains an accurate and timely computerized database utilizing
prescribed abstract format.
7. Maintains coding skills and professional credentials with appropriate
continuing education by reading and applying coding materials and policies.
8. Prepares or assists with the preparation of statistical or other special
reports relating to patients, diseases and treatments as needed.
9. Performs audits, quality checks and provides training to the trainees as
required.
10. Acts at all times as a service representative of the department. Provides
cross-coverage for other positions in the department as requested by the
management.
Bachelor's or Associate Degree/ Diploma in Medical Records Management or other
Medical Records related discipline is required.
One (1) year of related experience with Bachelor's Degree or three (3) years
with Associate Degree/ Diploma is required.
Completion of Hospital approved Coder Training Program is required.
Certified Coding Specialist (CCS) Certification is preferred.
Reviews patient medical records for relevant diagnostic and procedure information and assigns corresponding codes according to standard coding guidelines maintaining productivity. Assists with the maintenance of various patient indexes and databases. Provides patient information retrieval assistanc…
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