CODER

Description

Health Information is looking for an individual to join their team to code.

The regular duties that are included in this position are:

*Accurately track all admissions/discharges (inpatient), including some outpatient for statistical purposes (i.e. daily census).

*Assist in chart assembly and perform chart analysis. Analyzes medical records of discharged patients for completeness and accuracy according to department and hospital policy and procedures.

*File completed charts and be able to retrieve charts.

*Maintain accurate medical record numbers.

*Ensure accurate transcription of medical records (history & physicals, discharge summary, operative reports, consultations, progress notes, etc.)

*Responsible for coordinating the release of medical information to all requesters, including patients, physicians, and other healthcare providers. Maintain a computerized log of all requests.

*Reviews medical record thoroughly to ascertain all diagnoses/procedures. Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on medical record. Codes all diagnoses/procedures in accordance to ICD-10 and HCPCS coding principles and the Coding Manual. Refers medical record to Director, if there is a question regarding the diagnoses/codes.

Requirements

The preference would be a candidate with experience/knowledge of coding. Certification is preferred, but not required.