Medical Records Coder

Overview

PURPOSE STATEMENT

Responsible for assigning ICD-10-CM diagnostic and procedural codes to patient accounts.

Responsibilities

ESSENTIAL FUNCTIONS

• Assign appropriate codes using International Classification of Disease system (ICD-10) and/or Current Procedural Terminology (CPT) for diagnosis, procedures and services.
• Responsible for correctly coding claims based on the services a patient receives in order to obtain reimbursement from insurance or government healthcare programs.
• Read and analyze patient records extracting precise information from documentation, test results and reports.
• Request diagnosis from physicians when not recorded on discharge and in cases where information is incomplete.
• Maintain confidentiality regarding patient care information and chart contents.
• Inform administrator of any incongruences noted in the chart record.
• When appropriate clarify diagnosis, conditions and treatment information by working with the physician according to company policy and procedure.
• Process physician reports needed to code appropriately and accurately.

OTHER FUNCTIONS

• Perform other functions and tasks as assigned.

Qualifications

EDUCATION/EXPERIENCE/SKILL REQUIREMENTS

• High school diploma or equivalent required.
• Certificate or associate’s degree in medical coding or related field preferred.
• Two or more years’ of medical billing/collections/coding preferred.
• Strong knowledge of anatomy, physiology and medical terminology required.

LICENSES/DESIGNATIONS/CERTIFICATIONS

• Medical Coding Certificate preferred.

ADDITIONAL REGULATORY REQUIREMENTS

While this job description is intended to be an accurate reflection of the requirements of the job, management reserves the right to add or remove duties from particular jobs when circumstances (e.g. emergencies, changes in workload, rush jobs or technological developments) dictate.

We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.

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