MINIMUM KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

High school graduate (or equivalent) and

Associates degree in related field with RHIA, RHIT credential.

Prefer six to twelve months experience in a hospital Medical Records Department and demonstrated knowledge of  medical terminology, various types of diseases and surgical procedures, and knowledge of ICD-9-CM, ICD-10-CM and CPT-4 classification manuals.

Analytical ability to interpret data contained in records.

Ability to accurately determine and assign ICD-9-CM, ICD-10-CM and CPT-4 codes.

Interpersonal ability necessary to communicate with all Medical Center associates and physicians.

Visual acuity necessary to scan documents and classification manual and to read and decipher handwriting.

Ability to determine to whom medical record information may be released.

Mathematical skills/ability to perform statistical calculations.

Ability to perform minimal typing.

PRINCIPAL DUTIES AND RESPONSIBILITIES

Principal duty is to review medical records for diseases and surgeries performed and assigns codes according to the International Classification of Disease and Operations for indexing purposes and CPT-4 coding manual for inpatients and outpatients.  Knowledge of EM coding for emergency room department.

Assigns correct/proper codes to patient records.  Works with DRG/UR Coordinator to prepare diagnosis codes for DRG reimbursement system.

Codes necessary diagnoses and operative procedures for billing purposes and DRG reimbursement.

Codes final diagnosis and procedures as the charts are completed by the physician.

Monitors quality of source document (i.e., medical record) to insure consistency and validity of data.

Insures compliance with the PRO data reporting requirements.

Performs data entry for outpatient billing release.

Performs QA data retrieval as assigned.

Assists Department Manager as assigned in statistical compilation.

Assists in compliance with data reporting requirements established by regulatory licensing and accrediting agencies (Cancer registry, MRI scan data, etc.).

Maintains current knowledge of ICD-9-CM, ICD-10-CM and CPT-4 coding skills.

Performs related duties such as filing, pulling patient charts, typing, answering phones and other duties as assigned.