Coder - PMH - Medical Records
New Hanover Regional Medical Center - Wilmington, NC

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Coder - PMH - Medical Records

Department:
Medical Records

Schedule:
full-time

Shift:
DAY

Hours:

Job Details:
  • This position is located at Pender Memorial Hospital in Burgaw, NC.

    **Current NHRMC employees applying to this position should complete a Pender Memorial Hospital external application by clicking below the job description on Click Here to Apply Online . This position would not be considered an internal transfer for an NHRMC employee.

    This position has access to and knowledge of extremely sensitive, private and confidential materials. Ability to maintain the highest standard is required with zero tolerance.

    All the primary duties within this document will be performed according to established policies, procedures and guidelines within the department and the Medical Center.

    JOB SUMMARY:

    Works under the supervision of the HIM Manager. Responsible for accurately coding inpatient and outpatient records. Analyze the records for completeness to assure capturing of appropriate diagnoses. Process release of information. Ability to transcribe and process dictation correctly.

    PRIMARY JOB DUTIES:

    1. Accurately codes the hospital discharge record by abstracting information on the face sheet and from the body of the record; code Emergency Room records and outpatient records.

    2. Optimizes for reimbursement by scanning the hospital discharge record for diagnostic and procedural information to substantiate the hospitalization; analyzes the record for completeness of face sheet, operative reports, discharge summaries and appropriate signatures on designated documents; demonstrates a high degree of accuracy and attention to detail at all times.

    3. Works when scheduled plus assists in any additional hours as needed.

    4. Transcribes and processes dictation correctly and in a timely manner.

    5. Process medical/surgical correspondence and releases.

    6. Works with customers regarding Release of Information.

    7. Demonstrates standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.

    8. Performs other duties as assigned.

    ESSENTIAL JOB SPECIFICATIONS:

    1. Education: High School graduate or equivalent required.

    2. Licensure/Certificate: Coding Certification preferred.

    3. Experience: Two years coding experience preferred.

    4. Other (hours of work): Work schedule is Monday - Friday, 8:00AM to 4:30PM. Additional hours as needed.

    5. Population Served: Neonates Infants Pediatrics Adolescents (12 – 17 years) Adults (18 – 71 years) Geriatrics ( 72 + years)

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