Medical Records Coder in a healthcare center that helps improve coding, documentation, and billing accuracy on encounter data for services performed in the medical group.
1. Responsible for review of Medical Record Charting. Identify coding and documentation deficiencies.
2. Ensure Encounter form coding accuracy.
3. Maintain current knowledge of medical service coding and guidelines.
4. Monitor accuracy of physician documentation and coding for compliance.
5. Assist with the continuous quality improvement process to identify coding training needs and assure timeliness of encounter completion.
6. Responsible in the communication to physicians and medical staff on the importance of medical record charting and coding accuracy.
7. Perform as a team member with other coders and providers to improve and maintain coding processes.
8. Identify inefficiencies in physician billing and coding to enhance encounter capture.
1. Accepts the need for change and willingly adjusts to new work processes.
2. Ability to positively handle challenges and diverse approaches to work and develops solutions to problems.
3. Looks for opportunities for process improvement and reports that information to appropriate person.
Enhance Customer Service
1. Demonstrates a commitment to excellent customer service at all times.
2. Treats customers with dignity/respect.
3. Maintains patient confidentiality.
1. Equivalent of high school diploma with college preferred. CPC (Certified Professional Coder through AAPC) or CCS-P (AHIMA Coding Specialist) or ability to obtain within one year of employment.
2. Strong knowledge in medical terminology, anatomy and physiology, ICD-9 and CPT-4 coding with 2 or more years of working knowledge required.
3. Medical records auditing experience required.
4. Procedural Coding Certification required.
5. Good verbal and written communication skills required.
6. Strong internal and external customer service skills.
7. Microsoft skills required in both Word and Excel.
8. Experience with E&M (Evaluation and Management) and HCC (Hierarchical Condition Categories) coding preferred.
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