Job Title
Medical Records Clerk/Coder
Department
Medical Records/Health Information Management (HIM)
Reports To
Supervisor of Medical Records
Position Summary
Assign diagnostic and procedure codes, check records for completeness, correct claim charges, keep updated on coding guidelines, scan records, assist patients and coworkers, perform release of information functions.
Qualifications and Requirements
License and Certifications Preferred: RHIA, RHIT, CCA, CCS
Educational Requirements:
Must be able to read, write, speak and understand English
High School Education
Health Information Management degree preferred
Experience Requirements: Computer experience with Microsoft Word and Microsoft Excel
Special Skills or Training:
Knowledge of medical coding, medical terminology, and medical record technology.
Skills in English grammar, composition and communication.
Skills in establishing and maintaining working relationships with staff.
Ability to maintain confidentiality.
Physical Requirements:
Prolonged sitting and standing; walking, bending, lifting, grasping, fine hand coordination
Ability to use office equipment such as computer, copy machine, scanner, label maker, telephone and printer.
Essential Duties and Responsibilities
Code diagnoses and procedures on clinic, nursing home, inpatient, emergency room, and outpatient records, using the ICD-10-CM, CPT and HCPCS coding books.
Check completed records, including lab orders and medication charges, to ensure all diagnoses are listed by the provider and all reports are in the record and all entries are properly signed.
Confirm the listing of diagnoses and query the provider if changes are needed.
Document discrepancies, errors, or omissions on records and work with staff for corrections.
Maintain helpful and cooperative relationships with staff and other employees in the facility and other healthcare institutions.
Fax, email, or mail copies of records for which there is a request with proper authorization.
Locate and retrieve records requested by authorized staff.
Scan documents into the electronic medical record.
Maintain Resident and Patient confidentiality.
Know and comply with Residents' Rights rules.
Treat Residents, Patients, Visitors and coworkers with kindness, dignity, and respect at all times.
Attend and participate in orientation, training, mandatory education, in‑services, staff meetings, and education courses as instructed to improve knowledge and skills.
Promote teamwork; encourage others to work to the best of their ability; assist with training of new co‑workers, if needed.
Maintain a positive attitude; accept change willingly; follow facility rules, regulations, and job assignments; accept suggestions for work improvement; perform well with minimum supervision; comply with supervisor guidance and show respect at all times; speak well of company and job.
Have a record of punctuality and minimal absences; provide timely notice of absences; take allowed time for breaks.
Follow company dress code.
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