Job Description:
Under general direction, responsible for assigning diagnostic and procedure codes to records of outpatients, including Emergency encounters and assignment of the E & M coding, Observation, Same Day Surgery, assigning professional (profee) codes for the Hospitalist and Anesthesiologist. Performs all duties as required within the department and hospital policies and procedures. The Health Information Management Department Coding Technician II provides quality services to all customers (e.g., patients, physicians, and employees), who require assistance. Services might include physician support, billing support, audit support, document improvement (CDI), and a member of designated Committees as assigned by the HIM Director. Treats customers, peers and others with kindness and respect under all circumstances. Completes other duties as assigned.
Essential Functions:
- Possess knowledge of hospital and departmental policies and procedures
- Possess knowledge of EHR functions to guide users in amendments, corrections, and retractions
- Ensure release of information is completed according to policy
- Retrieve electronic medical records for internal and external requests as appropriate (e.g., release of information, audits, review)
- Answers telephone and provide information regarding medical records as required per policy
- Maintains confidentiality and adheres to HIPAA guidelines and GMC’s policies and procedures
- Assists the HIM Department in clerical, secretarial, and assistant duties
- Prepare, scan, verify, and index paper documents into EHR
- Provide technical and administrative assistance for other health information services functions
- Follow five fundamentals of patient communications: Acknowledge, Introduce, Duration, Explanation, Thank You (AIDET)
- Communicates in a professional manner with the Medical Staff and their clinic staff
- Supports, promotes, and adheres to the Standards of Behavior
- Adheres to the National Patient Safety Goals
- Performs other related duties as needed to support the achievement of department goals and objectives
- Performs other duties as assigned
Job Requirements:
Licenses or Certifications:
One or more of the following:
- RHIT (Registered Health Information Technician)
- RHIA (Registered Health Information Administrator)
- CCS (Certified Coding Specialist)
- CCS-P, CPC, or equivalent advanced coding certification
Work Experience: 2 years experience in a related role/field
Required Knowledge or Skills:
- Working knowledge of coding/abstraction, medical terminology, ICD-10-CM, CPT, APCs and DRGs
- Strong computer skills (Microsoft Office products)
- Effective interpersonal communication skills to acquire needed information and maintain cooperative work relationships with physicians
- Excellent communication skills
- Exceptional organizational/Time management skills, verbal and written communication skills required
- Ability to organize work priorities and meet specific objectives under time constraints
- Ability to manage multiple tasks simultaneously
- Good problem-solving skills and attention to detail
- Ability to be a team player in a team-oriented environment
- Proficient at 10 key
- Ability to use fax, photocopier, PC, microfiche reader/printer, scanner
Physical Demands:
- Lifting- Occasional: maximum of 30 lbs. from floor to chest height, 1 x year.
- Transfers: None
- Push/Pull: Minimal force required to pushcart of records, 1 x day for 300 yards.
- Carry: Maximum of 3 lbs. for 100 yards. Medical records and papers.
- Computer: 95% of day, 20% mouse, 80% data entry.
- Fine Motor: High degree for data entry, manipulations papers, clips, etc.
- Standing: Up to 1 hour at one time and 1 hour in one day.
- Sitting: Up to 3 hours at one time and 7.5 hours in one day.
- Kneeling: Up to 1 minute at one time and 20 minutes in one day.
- Stooping: Up to 1 minute at one time and 20 minutes in one day.
- Driving: None.
- Climbing: Up to 1 minute at one time and 2 minutes per day.
- Other: Constant talking, hearing, and seeing to interact with staff, physicians, patients, and vendors.
Environmental Conditions: Locations: Inside. Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. Occasional pressure to meet deadlines. Requires judgment and action. May be exposed to unpleasant customers. Minimal exposure to biohazardous materials. Some exposure to cleaning chemicals and dust.
