MEDICAL RECORDS CLERK/HIM Tech I
About The Position
POSITION SUMMARY: The HIM Coder/Technician I is responsible for ensuring patient record documentation meets state and federal regulations to support accurate and complete coding/billing for services provided. This position will apply all official coding guidelines when assigning diagnostic and procedure codes for both inpatient and outpatient accounts, working with the clinical team and ancillary departments to assure accuracy of charges and code assignments. In addition, this position will assist the Revenue Cycle Director with daily activities of the department, including release of information (ROI), scanning and validating paper documents, compiling statistics, gathering data for trauma and cancer registries, filing, monitoring transcription services, managing physician delinquencies, maintenance of data dictionaries, and other duties as assigned. SCHEDULE: Monday-Friday, 8am-Noon
Requirements
- High School Diploma required
- Experience interpreting a variety of instructions in written, oral, diagram, or schedule form.
- Must have education or experience to possess above-average medical terminology knowledge.
- Possess excellent interpersonal communication skills in both written and oral form.
- Understanding of data analysis, research, and error-correction
- Strong organizational and teamwork skills.
- Experience with Microsoft Office programs, e.g. Word, Excel, and Outlook, and Electronic Medical Records (Meditech preferred).
Responsibilities
- Ensure patient record documentation meets state and federal regulations for content, completeness, and timeliness.
- Abstract encounter details and assign accurate diagnostic and procedural codes to ED, Outpatient, Surgery, Rural Health Clinic, Specialty Clinic, and Inpatient accounts. To ensure coding guidelines are followed, the coder is furnished with appropriate reference tools, such as 3-M encoder, Code Correct, and ICD10-CM, ICD10 PCS, and HCPCS coding books.
- Accurately completes chart review to ensure accuracy and completeness for analytical, statistical, payment, and patient care purposes.
- Contact providers and ancillary departments to clarify diagnoses and ordered procedures when needed.
- Assures timely completion of chart deficiencies by promptly recording such deficiencies in the ICR desktop and by providing healthcare staff with the information they require to complete the deficiencies.
- Refer inconsistent or incorrect coding by provider to management when a trend or pattern is identified.
- Assist with requests for copies of medical records ensuring HIPAA compliance guidelines are met.
- Assist with scanning/validating requirements for incoming paperwork.
- Assist with maintaining accurate logs, e.g. admission/discharge, census, etc.
- Review Nuance site for any issues with outsourced transcription and resolve issues.
- Responsible for establishing and maintaining healthy interpersonal relationships with all staff members.
- Recognize the important part this position plays in regard to compliance and quality performance measures.
- Reacts properly and follows correct policy and procedure in an emergency and/or disaster.
- Must wear Personal Protective Equipment (PPE) as situations require maintaining Infection Control standards set by hospital
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What This Job Offers
Job Type
Part-time
Career Level
Entry Level
Industry
Hospitals
Education Level
High school or GED
Number of Employees
101-250 employees
