Performs basic medical record functions such as filing, thinning, release of information, coordination of transcription, assembly of discharged records, and analysis of discharged records for physician and other interdisciplinary team member deficiencies.
Performs scanning duties of discharged records and assists HIM Manager with record retention and purging.
Assists HIM Manger in assigning diagnoses/procedures codes to medical records using ICD-10-CM coding system.
Assists HIM Manager in assigning initial codes within 3 days of admission and updates codes throughout the patients hospitalization with the final coding completed within 3 days of discharge, excluding weekends or holidays.
Works with physicians and other clinical staff to clarify diagnoses and/or documentation issues relating to coding including notifying physicians of deficiencies, including time requirements for completion
Serves as a coding resource to other hospital staff that might have questions regarding the meaning of certain codes.
Stays current with all coding changes pertaining to the inpatient rehabilitation environment.
Responsible for maintaining confidentiality of all patient information.
Participates in the overall quality assessment and improvement activities and relevant training programs.
Assists in preparing reports for committee functions.
Perform other related duties and activities as directed and assigned by the Health Information Manager.
Must have completed at minimum a Medical Coder Certificate from an accredited school.
Minimum of CCA registration through the American Health Information Management Association.
Experience as an inpatient coder in a hospital is preferred .
Excellent oral and written communication and interpersonal skills.