Certified Medical Records Coder
Holy Name Medical Center - Teaneck, NJ

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Identifies and accurately codes hospital discharge records for purpose of reimbursement, research and statistics in compliance with federal regulations according to diagnosis, operations and procedures using ICD-9-CM classification.

Demonstrates thorough knowledge of human anatomy, physiology and medical terminology to interpret clinic data.

Understands sequencing rules for assigning appropriate MS-DRG for hospital billing.

Identifies each primary and secondary diagnosis with a Present on Admission indicator.

References the electronic medical record documentation (dictated reports, ER record, all

tests and procedure results, WebMAR, etc) in order to accurately complete the coding on

each account.

Verifies dates of service, patient type, discharge status and MS-DRG that was grouped on

each account coded.

Enters medical/ demographic data for each discharged patient into the computer system.

Appropriately queries the physicians for clarification of diagnosis and/ or procedures in order to ensure coding accuracy.

Attaches correct coding abstract printout to medical record.

Responds to MS-DRG/ coding inquiries from physicians and external agencies.

Informs Coding Manager and/or HIMS Supervisor of any “problem charts” (ie. Missing/ thinned charts, reports needed such as pathology, cath or operative reports, etc) in a timely manner.

Monitors DNFB on a daily basis to reach projected goal.

Meets productivity standards for inpatient coding.

Enhances personal growth and development through participation in educational programs, in-service meetings, workshops and department meetings.

Keeps current with Coding Clinic and CPT Assistant, grouper changes and new codes.

Provides education to physicians and other caregivers regarding clinical documentation, coding guidelines and coding issues.

Assists Core Measures team with identifying cases for review and assisting with any coding-related questions.

Works closely with CDMP team to establish the final DRG and review documentation issues.

Maintains chart control by electronically checking records in and out.

Follows through on recommendations for improved job performance and accepts and incorporates feedback on performance.

Confers with others and keeps co-workers updated and informed as necessary to ensure a functioning team.

Assists other coders with coding questions and issues to instill a team environment.

Displays courtesy, professionalism, and a positive business demeanor towards physicians, patients, visitors and co-workers.

Takes pride in the quality of work.

Maintains and respects patient confidentiality.

Maintains a clean, neat and professional appearance at all times.

Performs other duties as assigned by the Director/Coding Manager.

Date of Listing

Full Time Days

Minimum Qualifications
CCS certification, minimum of 5 years of acute inpatient coding experience. Good written and verbal communication skills. Experience with 3M encoder a plus.

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