Coder 1 / Health Information Analyst

Brodstone Healthcare•Superior, NE

About The Position

The Coder 1 / Health Information Analyst supports Health Information Management (HIM) operations by managing medical record documentation, scanning, coding support, regulatory reporting, record retrieval, release of information, and maintenance of accurate and complete patient health records in compliance with applicable laws, regulations, and organizational standards. The role requires proficiency with the 3M Encoder, ICD-10 and CPT coding rules and regulations, electronic medical record (EMR) systems, and other HIM technologies, along with the ability to adapt to new technology, software, and processes. The position also supports record completion and quality, assists with discharged-record review and coding-related work, prepares required reports and patient documentation, and responds to authorized requests for confidential health information. The employee is expected to follow Brodstone Healthcare’s mission, vision, values, standards of behavior, policies, and compliance requirements; participate in training and quality improvement activities; and support HIM and other departments as needed.

Requirements

GED or high school diploma required.
Proficiency with the 3M Encoder, ICD-10 and CPT coding rules and regulations, EMR systems, and other HIM technologies required to perform job duties.
Ability to continually learn and adapt to new technology, software, and HIM processes.

Nice To Haves

Associate degree in Health Information Management preferred.
Minimum of one year of medical terminology and transcription experience preferred.
Coding certificate with CCS-P or CCS preferred.
RHIT certification preferred.

Responsibilities

Adhere to Brodstone Healthcare’s mission, vision, values, and standards of behavior.
Work effectively in a team, accept supervisory direction, follow established rules and procedures, and respond positively to constructive feedback.
Review and manage electronic documentation, monitor documents, and ensure accurate record completion.
Scan complete patient charts and individual documents using desktop scanning equipment while maintaining document integrity and quality.
Assist with assembling, abstracting, coding, auditing, and reviewing discharged patient records for completeness, deficiencies, signatures, and required reports, and route records appropriately.
Compile and submit required state and organizational reports, including cancer registry, birth defect registry, monthly maternity reports, and other regulatory or statistical reports.
Assist with reviewing, editing, and transcribing medical, surgical, and clinical dictation as needed.
Complete birth certificates, type surgical permits, and process other required patient and clinical documentation accurately and promptly.
Locate, retrieve, and distribute medical records and charts to medical staff, departments, and other authorized users.
Respond to authorized requests for release of confidential patient health information in accordance with applicable laws, regulations, policies, and procedures, including providing appropriate information to insurance companies and other authorized entities.
Comply with facility policies, procedures, standards of conduct, regulatory requirements, and the organization’s Compliance Program; participate in compliance and quality improvement activities.
Attend and participate in departmental meetings, in-service training, quality improvement initiatives, and continuing education programs.
Support HIM department staff and other departments to help ensure efficient operations and continuity of services.
Perform other duties and responsibilities as assigned.