Medical Record Coder
At ScionHealth, we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking. Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates.
Job Summary
- Codes medical records, including all diagnoses, operative and diagnostic procedures in patient medical records, using the International Classification of Diseases and enters coded information into an automated system
Essential Function
- Using the coding system, assigns and records an accurate code to all diagnoses, procedures, and operations as documented in the patient medical record based on official coding guidelines
- Ensures that all factors necessary for assigning an accurate DRG (Diagnostic Related Group) are present, and that all diagnoses are ranked properly
- Contacts hospital designee regarding questions on diagnoses, need for greater detail or different terminology to assign accurate codes to medical records
- Enter final diagnostic codes for diagnoses and procedures into an automated grouper system
- Complies with internal procedures established to ensure compliance with regulatory agencies for all facilities
- Reports on potential coding discrepancies to HIM/Medical Records Manager and Business Office Manager to assure that only accurate and properly documented services are coded in accordance with Federal False Claims
- Provides information and responds to inquiries regarding medical documentation and DRGs to hospital staff
- Conducts job responsibilities in accordance with the standards set out in the Company’s Code of Business Conduct, its policies and procedures, the Support Conter Compliance Agreement, applicable federal and state laws, and applicable professional standards
- Promotes adherence to the Company’s Code of Business Conduct and the Support Center Compliance Agreement by monitoring employee performance and identifying and responding to compliance issues
- Abstracts and retrieves medical data for evaluation, planning, or research in health care and related programs
Knowledge/Skills/Abilities/Expectations
- Knowledge of medical terminology, International Classification of Diseases (ICD-9-CM) codes, current procedural terminology (CPT) and HCPCS level II codes as appropriate
- Ability to understand and code medical records
- Ability to communicate effectively both orally and in writing
- Exceptional organizational and follow-through skills
- Ability to maintain confidentiality of all patients and/or employee information to assure patient and/or employee rights are protected
- Approximate percentage of time required to travel: 0%25
- Must read, write and speak fluent English
- Must have good and regular attendance
- Performs other related duties as assigned
Education
- High School or equivalency diploma required
- College degree preferred
Licenses/Certification
- AHIMA Certified Coding Specialist (CCS) and/or eligibility to sit for the examination or Associate of Science degree with RHIT or Bachelor of Science with RHIA preferred
Experience
- 3 years acute care inpatient and/or outpatient coding as appropriate