Coder/Abstractor – Health Information Management

Job Description

Performs the essential duties and responsibilities and the primary function of Coder/Abstrator. Identifies and codes hospital medical records for the purpose of continuing patient care, reimbursement, and research in accordance with coding and reimbursement guidelines. Codes diagnosis(es), operations(s), and procedures(s) using the ICD-9-CM and CPT coding classification systems. Codes all Inpatient, Outpatient, Observation, Same Day Surgery, Emergency Room, and Urgent Care medical records for billing purposes and data retrieval. Abstracts relevant clinical and demographic information from the medical records using the hospital’s abstracting system and in accordance with established policies and procedures. Responsible for solving practical problems dealing with a variety of issues and interpreting a variety of instructions furnished in written or oral form. Demonstrates clerical knowledge and judgement necessary to complete the job responsibilities.

SHIFT AND SCHEDULE

Monday – Friday: 8:00 AM – 5:00 PM

ESSENTIAL FUNCTIONS/PERFORMANCE EXPECTATIONS

• Complies with the ICD-10-CM and CPT coding conventions and guidelines in the Coding Clinic and demonstrates a complete understanding of the coding convention.
• Complies with the UHDDS definitions of principal diagnosis, secondary diagnosis, principal procedure and secondary procedures
• Participates in coding meetings and education conferences in order to main coding accuracy.
• Abstracts relevant clinical data and demographic information from the medical record.
• Minimum Productivity Standard: Inpatient Charts=4 per hour; Observation/Same Day Surgery Charts= 6 per

EDUCATION AND EXPERIENCE

• A mental development equivalent to a high school graduate, capable of solving practical problems dealing with a variety of variables.
• Prefer six months to one year previous experience in the Health Information Management Department or related clinical setting.
• Prefer CCS or RHIT Certification.
• Computer keyboarding experience and clerical experience.

PHYSICAL REQUIREMENTS

To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

The individual must be able to:

• Stand, walk, sit, stoop, reach, lift, see, speak and hear. Lifting is limited to 35 lbs. for clinical staff and to 50 lbs. for non-clinical staff.
• The individual must use an assisted-lift device or get another individual(s) to assist with the lift that is over these maximum limits.

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