Coder I - Medical Records

Prime Healthcare • Lewiston, ME

4h • Onsite

About The Position

The Coder I reviews and analyzes documentation present in the medical record for both inpatient and outpatient visits to determine diagnoses and procedures as described by the physicians of record. Utilizing the International Classifications of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT), the Coder I translates the documented diagnosis and procedural information into coded data. Determination of code assignment is based on the official American Health Association (AHA) guidelines in addition to hospital specific and regulatory guidelines. The Coder I enters the coded data and other abstracted data from the medical record into hospital's electronic information system, facilitating the Health Information Services department's indexing responsibility for internal use (such as to support medical care evaluation studies), and mandated reporting requirements. Participates in chart review projects as assigned.

Requirements

• Minimum one year experience with ICD-9 and CPT coding in an acute care setting.
• Basic computer experience.
• Successful completion of college level courses in anatomy, physiology, medical terminology, and coding ICD and CPT.
• Successful completion of or current enrollment in a program for certification as a Certified Coding Specialist (C.C.S.), Registered Health Information Technician (R.H.I.T.), or Registered Health Information Administrator (R.H.I.A.).

Nice To Haves

• Use of an encoder software product for code assignment in an acute care setting.
• Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm.
• Certification or license as a Certified Coding Specialist (C.C.S.), Registered Health Information Technician (R.H.I.T.), or Registered Health Information Administrator (R.H.I.A.).

Responsibilities

• Reviews and analyzes documentation present in the medical record for both inpatient and outpatient visits to determine diagnoses and procedures as described by the physicians of record.
• Translates the documented diagnosis and procedural information into coded data utilizing the International Classifications of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT).
• Assigns codes based on official American Health Association (AHA) guidelines in addition to hospital specific and regulatory guidelines.
• Enters coded data and other abstracted data from the medical record into the hospital's electronic information system.
• Facilitates the Health Information Services department's indexing responsibility for internal use and mandated reporting requirements.
• Participates in chart review projects as assigned.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: Associate degree