North Shore Medical Center - Salem, MA

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Job ID:



S-Medical Records 4

Std Hrs/Wk:


Full/Part Time:



Under the general direction of the manager, health information management department, the coder is responsible for accurate coding of all inpatient, outpatient, including same day surgery, and emergency service diagnoses and conditions, working from the appropriate documentation in the health record of the patient. Classification systems include ICD-9-CM and CPT -4 as well as other specialty systems as required by diagnostic category. Assures appropriate assignment of DRG, APC and APG's. All work is carried out in accordance with the department's approved polices and procedures.

Required Skills:
Ability to process work, error free, within presented deadlines and time frames. Strong analytical skills. Ability to pay close attention to detail. Ability to work as a team player. Demonstrates the ability to assume responsibility for professional development and on-going education to maintain proficiency. Ability to accept constructive analysis based on feedback from inside/outside auditors, and quality improvement initiatives. Ability to maintain confidentiality with regard to all phases of the work. Ability to withstand the pressure of continual deadlines and receipt of work with variable requirements. Ability to be courteous, tactful, and cooperative throughout the working day. Ability to use judgment in carrying out all phases- of the work. Ability to communicate clearly, verbally. Subject to irregular hours occasionally. Frequent interaction with physicians and other department personnel. Ability to use standard office equipment including computers, photocopy and facsimile machines, and readers/printers. Possess in-depth knowledge of health record content and sequence.

Required Experience:
1+ years experience is generally required to gain an in-depth knowledge of coding/classification systems appropriate for inpatient, outpatient, and emergency care, specifically, ICD-9-CM, CPT and knowledge of E&M leveling is preferred. Experience in the use of coding software, specifically 3M/HIS.

Required Education:
Must possess High School Diploma or Equivalent.

Required License/Certificates:
Prefer a registered health information technician (RHIT), registered health information administrator (RHIA), and/or coder specialist (CCS),. or possess equivalent training in coding systems, advanced medical and anatomical terminology, clinical medicine theory, and reimbursement principles.

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