Job Description

Job Title: Medical Records Clerk/Coder
Department: Medical Records/Health Information Management (HIM)
Reports To: Supervisor of Medical Records
Position Summary:
Assign diagnostic and procedure codes, check records for completeness, correct claim charges, and keep updated on coding guidelines, scan records, assist patients and coworkers, perform release of information functions.
Qualifications and Requirements:
1. License and Certifications Preferred: RHIA, RHIT, CCA, CCS
2. Educational Requirements:
• Must be able to read, write, speak and understand English
• High School Education
• Health Information Management degree preferred
3. Experience Requirements: Computer experience with Microsoft Word and Microsoft Excel
4. Special Skills or Training:
• Knowledge of medical coding, medical terminology, and medical record technology.
• Skills in English grammar, composition and communication.
• Skills in establishing and maintaining working relationships with staff.
• Ability to maintain confidentiality.
5. Physical Requirements:
• Prolonged sitting and standing; walking, bending, lifting, grasping, fine hand coordination
• Ability to use office equipment such as computer, copy machine, scanner, label maker, telephone and printer.
Essential Duties and Responsibilities:
1. Code diagnoses and procedures on clinic, nursing home, inpatient, emergency room, and outpatient records, using the ICD-10-CM, CPT and HCPCS coding books.
2. Check completed records, including lab orders and medication charges, to be sure all diagnoses have been listed by the provider and that all reports are in the record and all entries are properly signed.
3. Confirm the listing of diagnoses and query the provider if there are changes to be considered.
4. Make note of discrepancies, errors, or omissions on records and work with staff for corrections.
5. Maintain helpful and cooperative relationships with staff and other employees in the facility and staff and other employees of other healthcare institutions.
6. Fax, email, or mail copies of records for which there is a request with proper authorization.
7. Locate and retrieve records requested by authorized staff.
8. Scan documents into electronic medical record.
9. Maintain Resident and Patient Confidentiality.
10. Know and comply with Residents' Rights rules.
11. Treat Residents, Patients, Visitors and Co-workers with kindness, dignity and respect at all times.
12. Attend and participate in orientation, training, mandatory education, in-services, staff meetings and education courses as instructed to further improve knowledge and skills.
13. Promote teamwork; encourage others to work to the best of their ability; assist with training of new co-workers, if needed.
14. Have a positive attitude; accept change willingly; follow facility rules, regulations and job assignments; accept suggestions well for work improvement; perform well with minimum supervision; do what is requested without complaint; cooperate with supervisor and show respect at all times; speak well of company and job.
15. Lack of absences and tardiness; give timely notice of absences; take allowed time for breaks.
16. Follow company dress code.

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