JOB SUMMARY

Under the direction of the Business Office Manager, is responsible for assuring that inpatient and out patient medical records are coded and abstracted according to established criteria utilizing available resources both automated and manual based on documentation in the medical record provided by the attending, consulting physicians and clinical information. Using the available automated systems, enters coded documentation in the medical records on a daily basis. Communicates with consultants, federal and state organizations to validate the coding process and assure compliance to prevent fraud and abuse related to coding and abstracting. Validates documentation and works with the physicians to assure proper coding and educates the medical staff regarding coding issues.

DUTIES AND RESPONSIBILITIES:



1.Code diagnoses, procedures, complications and co-morbidities for inpatients and out- patients accurately.
2.Code appropriately for ancillary services.
3.Demonstrates knowledge and remains current in regard to ICD''s current version, CPT codes, modifiers, APCs, and DRGs.
4.Remains current with the coding and processing of records to assure timely coding.
5.Assures that the proper documentation is available in the medical record prior to coding. Enters codes for each provider and assures that the record is complete to assure that it is accurately abstracted. Follows through to assure the coding is finalized and a claim has been generated.
6.Utilizes the available automated systems to achieve peak efficiency and accuracy.
7.Demonstrates expertise in the use of the automated systems and any other that may pertain to coding.
8.Maintains required certification and training in the area of coding and abstracting.
9.Interacts positively, friendly and professionally with physicians, patients/family, office staff, hospital staff, medically supply and drug company representatives, insurance companies, attorneys, worker''s compensation adjusters and others.
10.Identifies opportunities to teach co-workers, medical staff and professionals regarding the documentation of medical care which supports accurate coding.
11.Speaks clearly, concisely and with consideration and respect in a group or one-on-one. Articulates thoughts wells and has a good rapport with listeners. Communication is clear, concise and understandable. Presentation is always polite, considerate and patient. Listens well.

SKILLS AND ABILITIES:



1.Able to work independently and meet established deadlines.
2.Able to make sound reasonable decisions.
3.Highly organized.
4.Ability to concentrate on many detailed requests despite numerous interruptions and respond accordingly with an appropriate sense of urgency.
5.Demonstrates accountability, professionalism, openness, receptive to change, creativity and innovation.
6.Ability to identify and calmly handle inherently stressful situations with tact.
7.Excellent communication skills.
8.Ability to develop excellent working relationships with consumers, vendors and staff.
9.Seeks guidance, direction and assistance when needed.



BENEFITS
Our competitive salary and benefits package includes medical and dental insurance, 401(k), paid time off and life insurance.

EDUCATION, TRAINING AND EXPERIENCE REQUIREMENTS:


1.3 - 5 years in medical environment with experience coding in a hospital environment (including orthopedics, pain management, surgical (general, gynecological, ENT), radiology and emergency room. Certification required. (American Health Information Management Association (AHIMA), the American Academy of Professional Coders (AAPC) or other nationally recognized authority on hospital coding)
2.4 year degree in business or clinical area or equivalent work experience.
3.Must be able to communicate and understand the English language both verbal and written.
4.Computer literate. Experience and knowledge of Advantx and Microsoft Office product required.
5.Knowledge of medical terminology.