Coding Specialist, Medical Records, 20 Hours, Any Shift

Hours: Per Diem

Summary:
The Coding Specialist will review medical records within the Heywood/Athol/ HMG EMR to abstract the diagnosis based
on the documentation. The Coder will serve to add diagnosis and CPT codes to surgical and other outpatient types of
accounts. The Coder will also notify the coding Manager, Medical records, and other coders as needed to for
deficiencies in documentation. The coder is responsible for accurate and timely abstracting of all assigned accounts
within the Expanse and 3M system.

Essential Functions

• Acquires the knowledge to keep up with changes in technology and regulations.
• Shares knowledge and expertise to help others improve performance.
• Continuously prioritizes projects, activities, and tasks to ensure deadlines and customer needs are met.
• Reviews medical records to code accurately all diagnoses and/or procedures using coding guidelines.
• Enters all codes into the Meditech Computer System, via 3M HDIM Systems by accessing the proper account using the medical record number and date.
• Creates and runs a list of unbilled accounts on a weekly basis
• Utilizes the list of unbilled accounts to track electronically and if needed pulled manually, to attain the correct codes so the accounts can be billed and eliminated from the unbilled report.
• Collaborates with the Director Of HIM or Supervisor of Daily Operations to assess coding needs in certain areas when volume increases so that all accounts are coded and are able to be billed.
• Examines information given to ensure all needed information is present and maintains good communication with the physicians, other Medical Records Staff, and all personnel throughout the hospital so that coding can be done accurately and timely as needed without communication breakdowns
• Examines information given to ensure all needed information is present and maintains good communication with the physicians, other Medical Records Staff, and all personnel throughout the hospital so that coding can be done accurately and timely as needed without communication breakdowns
• Retrieves any missing documentation and information from physicians and other departments prior to coding so that the coding can be done accurately and as scheduled.

Statement of Other Duties:

This document describes the major duties and responsibilities for this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that employees may be asked to perform job-related duties beyond those explicitly described.

Functional Demands

Physical Requirements:

Exerts up to 20 pounds of force occasionally, and/or up to 10 pounds of force frequently, and/or a negligible amount of force constantly to move objects.  Frequently reaches (extending hands and arms in any direction), and handles (seizing, holding, grasping, turning, or working with hands).

Organizational Expectations

Behavioral Attributes

The following behavioral attributes are required: achievement motivation, flexibility, concern for order, initiative, self-confidence, self control, customer service orientation, interpersonal effectiveness, teamwork and information seeking.

Job Requirements

Minimum Education

Licenses/Certifications

• CPC or equivalent required in addition to an RHIT or equivalence in a two-year training program

Minimum Work Experience

• Experience in ICD and CPT as well as Evaluation and Management Coding preferred
• Exposure to computerized abstracting/data entry and PC knowledge base is required.

Required Skills

• Ability to comprehend and accurately interpret all aspects of medical documentation as relative to coding needs. 
• Aptitude for precise, complex and detailed clerical work is required. 
• Ability to follow specific, detailed procedures and routines is mandatory.