Coder

Job Summary Coder I

The Coder I is responsible for analyzing medical records for completion; performing coding and abstracting functions and efficiently navigating the electronic medical record to find patient information required for coding. The Coder I is responsible for functioning as a record reviewer for the Emergency Department medical records and determining appropriate charge levels for each patient and performing periodic audits to ensure that Emergency Department patients are being charged according to regulatory compliance.

Licensure and Certification:

N/A

Education:

High School diploma or GED equivalent

Medical Terminology

Anatomy and Physiology

AHIMA approved coding seminars/classes or other approved form of coding training

Experience:

One year acute care hospital experience

Knowledge and Skills:

Knowledge of ICD-9 CM and CPT

Understanding of UHDDS

Computerized medical records coding and abstracting experience desired

Knowledge of APC, E&M coding, modifier usage

Ability to use encoder at entry level

Ability to code clinical outpatient and emergency department records

Physical Demands - Clerical/Administrative Non-Patient Care:

Frequent sitting and standing/walking with frequent position change.

Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.

Occasional/intermittent reaching at or above shoulder level.

Occasional/intermittent bending, squatting, kneeling, pushing/pulling, twisting, and climbing.

Occasional/intermittent lifting and carrying objects/equipment weighing up to 25 pounds.

Continuous use of near vision, hearing and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.

Key for Physical Demands

Continuous

66 to 100% of the time

Frequent

33 to 65% of the time

Occasional

0 to 32% of the time

Job Summary Coder II

The Coder II is responsible for analyzing medical records for completion by Medical Staff, clinical or ancillary department; performing coding and abstracting functions and efficiently navigate the electronic medical record to find patient information required for coding. Coder II can review and accurately abstract medical records for quality assessment screens.

Licensure and Certification:

CCS required

RHIT or RHIA strongly preferred

Education:

Associate Degree in Health Information Technology or Information Technology or equivalent

Medical Terminology

Anatomy and Physiology

AHIMA approved coding program or equivalent with documentation of successful completion

Experience:

Acute hospital experience in an acute care hospital, with two years of inpatient and outpatient coding experience utilizing automated encoder.

Knowledge and Skills:

Extensive knowledge of ICD-9-CM and CPT

Understanding of UHDDS

Computerized medical records coding and abstracting experience – at least one year.

Experience analyzing and manipulating data from medical records coding and abstracts. Knowledge of APCs, E&M coding, Modifier usage

Ability to utilize encoder at intermediate level

Computer to maintain current status of coding process

Ability to code intermediate level inpatient, outpatient and Emergency Department records

Physical Demands - Clerical/Administrative Non-Patient Care:

Frequent sitting and standing/walking with frequent position change.

Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.

Occasional/intermittent reaching at or above shoulder level.

Occasional/intermittent bending, squatting, kneeling, pushing/pulling, twisting, and climbing.

Occasional/intermittent lifting and carrying objects/equipment weighing up to 25 pounds.

Continuous use of near vision, hearing and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.

Key for Physical Demands

Continuous

66 to 100% of the time

Frequent

33 to 65% of the time

Occasional

0 to 32% of the time

Job Summary Coder III

The Coder III is responsible for analyzing medical records for completion by Medical Staff, clinical or ancillary department; performing coding and abstracting functions; efficiently navigate the electronic medical record to find patient information required for coding; and accurately abstract medical records for quality assessment screens.

Licensure and Certification:

CCS required

RHIT or RHIA strongly preferred

Education:

Associate Degree in Health Information Technology or Information Technology or equivalent is minimum requirement

Medical Terminology

Anatomy and Physiology

AHIMA approved coding program or equivalent with documentation of successful completion.

Experience:

Acute hospital experience in an acute care hospital, with three years of inpatient and outpatient coding experience utilizing automated encoder.

Knowledge and Skills:

Extensive knowledge of ICD-9-CM and CPT

Understanding of UHDDS

Computerized medical records coding and abstracting experience – at least one year.

Experience analyzing and manipulating data from medical records coding and abstracts. Knowledge of APCs, E&M coding, Modifier usage.

Ability to utilize encoder at advanced level

Ability to utilize computer to maintain current status of coding process

Ability to code advanced level inpatient, outpatient and Emergency Department records

Physical Demands - Clerical/Administrative Non-Patient Care:

Frequent sitting and standing/walking with frequent position change.

Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.

Occasional/intermittent reaching at or above shoulder level.

Occasional/intermittent bending, squatting, kneeling, pushing/pulling, twisting, and climbing.

Occasional/intermittent lifting and carrying objects/equipment weighing up to 25 pounds.

Continuous use of near vision, hearing and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.

Key for Physical Demands

Continuous

66 to 100% of the time

Frequent

33 to 65% of the time

Occasional

0 to 32% of the time