Medical Records Coder managing inpatient and outpatient coding compliance with federal regulations. Conducting quality reviews of coding and maintaining up-to-date guidelines for accuracy and compliance.
Responsibilities
Reviews, interprets, and assigns diagnostic and procedural codes based upon medical record documentation according to correct coding principles.
Provides skilled and specialized technical work in documentation and coding for medical billing, abstracts complex patient-related data from medical records and coding of diagnoses and procedures using ICD-10 and CPT codes.
Works coding related charge review and claim edits daily to ensure timely and accurate billing.
Researches and resolves coding related issues, and assists in meeting productivity and quality standards.
Contacts other facilities to obtain medical records and information need to bill for services rendered.
Verifies fee tickets and physician notes for completeness to include abstracting and entering relevant medical information from the medical records; checks for required signatures; assures proper documentation guidelines are followed.
Interacts with regulator classification agencies and patients when clarification and additional information is required for documentation.
Reviews charge documents for completeness.
Updates coding books with changes as accepted and published by regulatory agencies.
Performs all other duties as assigned.
Requirements
Five (5) years experience in medical record abstraction and coding is required.
High school diploma or GED is required.
Benefits
Proficiency in ICD-10 and CPT coding
In-depth understanding of medical terminology, anatomy and physiology
Meticulous attention to detail and accuracy
A solid customer service acumen and interpersonal skills to effectively work with both internal and external customers and responds to requests in a timely and respectful manner
Strong verbal, written and interpersonal communication skills.
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