Coder

Job Summary  

Responsible for reviewing patients’ medical records after a visit and translating the record into codes that insurers use to process claims from patients. Their duties include confirming treatments with medical staff, identifying missing information and submitting queries when appropriate.

Essential Functions

• Responsible for making sure CPT, HCPCS, ICD-10 codes are assigned correctly and sequenced appropriately as per government and insurance regulations. 
• Insuring compliance with medical coding guidelines and policies.
• Reviewing patients’ records and documents for verification and accuracy.
• Following up and clarifying any information that is not clear to other staff members.
• Strong understanding of 
• Appropriately querying providers per coding guidelines.
• Ensure all codeshare current and active  
• Observe confidentiality and safeguards of all patients’ related information.
• Maintain a good working relationship within the department and other departments.
• Adhere to hospital requirements, policies, and standards.
• Provide excellent customer service.
• Answering phone line in the department.

Non-Essential Functions

• Perform other duties as assigned.
• Release of information
• Document Capture

Professional Requirements

• Adhere to dress code, appearance is neat and clean.
• Complete annual education requirements.
• Always maintain patient confidentiality. 
• Report to work on time and as scheduled.
• Wear identification while on duty.
• Maintain regulatory requirements, including all state, federal and local regulations. 
• Always represent the organization in a positive and professional manner.
• Comply with all organizational policies and standards regarding ethical business practices.
• Communicate the mission, ethics, and goals of the organization.
• Participate in performance improvement and continuous quality improvement activities.
• Attend regular staff meetings and in-services.

Qualifications

• High school graduate or equivalent.
• Minimum of five years’ experience in a related field.
• Minimum of two years’ experience in coding.
• Coding Certificates
• General computer knowledge.
• Previous hospital experience preferred.

Knowledge, Skills, and Abilities  

• Knowledge of health information management services.
• Strong organizational and interpersonal skills.
• Ability to determine appropriate course of action in more complex situations.
• Ability to work independently, exercise creativity, be attentive to detail, and maintain a positive attitude.
• Ability to manage multiple and simultaneous responsibilities and to prioritize scheduling of work.
• Ability to maintain confidentiality of all medical, financial, and legal information.
• Ability to complete work assignments accurately and in a timely manner.
• Ability to communicate effectively, both orally and in writing.
• Ability to handle difficult situations involving patients, physicians, or others in a professional manner.

Physical Requirements and Environmental Conditions  

• Work is performed during regular work hours, however, might require overtime and/or weekend hours to meet deadlines.
• Work in varying degrees of temperature (heated or air conditioned).
• Work under extreme pressures.
• Position requires sitting for approximately 4-6 hours per day and walking for 2 hours per day.
• Position requires light to moderate work with 50 pounds maximum weight to lift and carry.
• Position requires reaching, bending, stooping, and handling objects with hands and/or fingers, talking and/or hearing, and seeing.