Health Information Coder (Certified)
Category:Health Information Management (HIM)
Analyzes, codes, abstracts, and compiles medical records of patients of health care delivery system to document patient condition and treatment by performing the following duties.
Essential Duties and Responsibilities:
· Assign codes to diagnoses and procedures, using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes
· Ensure codes are accurate and sequenced correctly in accordance with government and insurance regulations
· Verify and ensure the accuracy, completeness, specificity and appropriateness of diagnosis codes based on services rendered.
· Interact with physicians, staff, and mid-levels to ensure accurate coding.
· Follow up with the provider on any documentation that is insufficient or unclear
· Search for information in cases where the coding is complex or unusual
· Receive and review patient charts and documents for accuracy
· Ensure that all codes are current and active
· Support and participate in process and quality improvement initiatives.
· Monitor completion of medical records in accordance with time standards
· Know the insurance filing deadline for timely coding
· Strong knowledge of anatomy, physiology and medical terminology
· Excellent written verbal and communication skills
· Excellent computer skills
· Other duties as assigned
Education and/or Experience:
High school diploma required. Associates or above preferred. One year of inpatient coding or 2 years of medical coding experience required.
Certificates, Licenses, Registrations:
AHIMA or AAPC certification required.
Open until filled