The Medical Records Coder Level 1 maintains a record of patient care by compiling, reviewing, and filing documentation of the patient’s condition, treatment, and health outcome. Codes ICD-10-CM, ICD-10-PCS, and CPT for all Inpatient, Emergency Room, and Outpatient records. The duties listed below are intended only as illustrations of the various types of work performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or a logical assignment to this job. Mains Health Information Management (HIM) Operations by following policies and procedures Mains the Master Patient Index in conjunction with the other departments at Franklin County Medical Center (FCMC) through an Electronic Medical Records (EMR) Completes medical records by reviewing information, notifying healthcare providers of record deficiencies, tracking outstanding records, and getting signatures on records Mains historical reference by abstracting and coding clinical data, such as diseases, operations, procedures, and therapies, using standard classification systems (SCS) Assigns diagnostic and procedural codes to all medical records using SCS Mains patient confidence and protects hospital operations by releasing information to third-party payors, law firms, government agencies, and patients, following the release of information policies Assists nursing staff in the Quality Management activities by retrieving medical records for their review May fill in the role of transcription/editor Consults with the Director of HIM to ensure that all legal and regulatory requirements for the department are met Maintain confidentiality by protecting sensitive, proprietary, or confidential information. Adhere to HIPAA privacy and security requirements Protects patients and employees by adhering to infection-control policies and protocols Must wear Personal Protective Equipment (PPE) as required to maintain Infection Control Standards as set by the facility Performs other related duties as assigned
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Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED