Position Summary: Analyzes, codes, abstracts, and compiles medical records of patients to document patient condition and treatment largely for billing purposes by performing the following duties personally. Responsible for ensuring that all critical tasks are fulfilled on a timely basis.
Critical Tasks:
- Ensures and requires that all data and information received for coding and input from providers is fully accurate, and notifies submitters if corrections are required.
- Accurately abstracts and codes diagnoses, treatments and procedures from health records by using appropriate classification systems, standards, and procedures.
- Utilizes and maintains continually updated knowledge and understanding of Current Procedural Terminology, Healthcare Common Procedure Coding, and International Statistical Classification of Diseases.
- Prepares fully accurate statistical reports required by legal, accrediting, licensing and regulatory authorities as well as by payers.
- Assigns patient severity of illness index ratings, supplemental codes, and other data as necessary.
- Compiles information and data from health records and computer systems for use in the evaluation of quality of care and utilization review.
- Monitors completion of medical records in accordance with time standards.
- Audits incomplete records and prepares reports on delinquencies.
- Ensures that management is notified of all delinquent issues and subjects.
- Confers with doctors, nurses, and other health personnel to assure complete, current, and accurate medical records.
- Compiles and maintains logs, reports, and statistical records, and researches records to locate health data as requested.
- Maintains and utilizes variety of health record indexes and storage and retrieval systems.
- Operates computers and databases to process, store, and retrieve health information.
- Assists in identification of medical records needed for research, using both manual and computer indexes.
- Complies fully with all patient medical privacy regulations, both state and federal.
- Maintains a high rate of productivity while ensuring that all job responsibilities are completed rapidly and with full accuracy.
- Maintains and continually updates knowledge and job performance methods according to changing requirements and regulatory mandates.
- Demonstrates ability to relate to diverse cultures and specifically the Gila River Community and/or other Native American cultures and community health services.
- Demonstrates ability to regularly change priorities to accomplish all tasks despite frequent interruptions.
- Demonstrates ability to clearly communicate, both orally and in writing, while performing all essential functions.
- Performs other special projects and duties as assigned.
Required Qualifications:
- High School diploma or GED required
- Certified Professional Coder (CPC through AAPC) required
- Two or more years full-time production coding experience preferred in a healthcare setting
- Prior health information management or healthcare revenue cycle experience a plus
- Demonstrated ability to relate to diverse cultures and specifically the Gila River Community and/or other Native American cultures.
- Strong communication skills with peers, providers and leaders
- Interest in medical subjects, patient services/care, and customer service.
