Department: Medical Records

Schedule/Status:

7:30am-4:00pm; Per Diem

Standard Hours/Week:

8

General Description: Under the supervision of the Coding Manager, evaluates the diagnostic and procedural information within the medical record to determine accurate coding classification for DRG or APC assignment for reimbursement of services rendered; verifies and abstracts clinical information into the organizational health database; and acts as the liaison to medical staff members and ancillary department personnel regarding coding documentation and assignment. The position shall exemplify the desired Culture of Choice® and philosophies of Parrish Healthcare.

Key Responsibilities:

Identifies, evaluates and assigns diagnostic and procedural codes based on record documentation for determination of appropriate APC/DRG with a minimum departmental accuracy level and within the established time parameters utilizing established coding classification methodologies.

With a minimum departmental accuracy level, abstract clinical administrative and financial information into the hospital’s database. Verify accuracy of existing information, making the appropriate corrections.

Prepares physician query form for clarification of documentation for coding purposes and forwards to coding manager, when appropriate.

Assists medical staff, ancillary departments, and other direct patient care providers on documentation, coding and APC/DRG assignments through education, communication and review of coding standards, chart documentation and organizational guidelines.

Maintains and continuously improves knowledge base of coding/APC/DRG/documentation requirements through review and study of resources (e.g., coding clinic, Medicare guidelines, etc.) and through continuing education.

Performs similar or related duties as assigned.

Knows fire, disaster and safety procedures and regulations as it pertains to the work area

Requirements:

Formal Education:

Vocational or other technical school, certification, training or apprenticeship required beyond high school.

Work Experience:

1 year to <2 years related medical field, preferably in billing or coding

Required Licenses, Certifications, Registrations:

Medical Terminology, Coding Classes, Human Anatomy Classes RHIA, RHIT, CCS or CPC-H certified within one (1) year of employment.