Job Description

Join Our Team as a HIM Coder I at Caribou Medical Center!

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Join our Health Information Management (HIM) team as a Medical Coder I, a pivotal role reporting directly to the HIM Supervisor. This position is central to ensuring the financial integrity and regulatory compliance of our facility by delivering precise and efficient coding across a diverse range of medical records.

Core Responsibilities:

1.

Coding of Outpatient Clinic and ER Records:

a. Accurately and promptly assign ICD and CPT codes to outpatient and ER records.



b. Ensure timely and accurate abstraction of accounts.



c. Query physicians when clarification is needed regarding diagnoses and procedures.



d. Monitor and address unbilled accounts, ensuring they are resolved swiftly.



e. Stay up-to-date on correct coding practices and guidelines.



f. Maintain current knowledge of CMS regulations for outpatient services.



2.

Coding of Outpatient Surgery Records:

a. Timely and accurate assignment of ICD and CPT codes to outpatient surgery records.



b. Abstract accounts promptly and accurately.



c. Collaborate with physicians to resolve any coding uncertainties related to diagnoses and procedures.



d. Review unbilled accounts and take appropriate action.



e. Remain informed on current coding practices and CMS guidelines for outpatient services.



3.

Coding of Inpatient and Swing Bed Records with DRG Assignments:

a. Assign ICD codes and DRGs for inpatient and swing bed accounts in a timely and accurate manner.



b. Promptly abstract accounts and ensure accuracy.



c. Seek physician clarification on diagnoses and procedures to ensure proper DRG assignments.



d. Monitor unbilled accounts and resolve any discrepancies.



e. Stay informed about appropriate coding practices and CMS regulations for inpatient services.



4.

General Department Assistance:

a. Support various departmental functions as needed, including handling release of information requests.



b. Complete assigned special projects efficiently and accurately.



5.

Health Information Reporting:

a. Generate requested reports using the abstracting module for Health Information purposes.



6.

Clerical Duties:

a. Organize and file completed medical records in compliance with departmental policies and procedures.



b. Ensure records are filed only after physician completion and accurate coding.



c. File records accurately within the Electronic Medical Record (EMR) system.



d. Retrieve records for statistical analysis, quality assurance, and final coding at the end of each month.



e. File both completed and incomplete records in appropriate storage areas after final analysis and review.



f. Scan and upload loose reports into the EMR, ensuring correct assignment to the corresponding patient records.



g. Ensure all necessary signatures are present and properly affixed.



h. Retrieve medical records and information for physicians, special studies, and various medical inquiries.

Other Duties as assigned: Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for their job. Duties, responsibilities, and activities may change at any time with or without notice.

General Responsibilities

Completes required education/skill/competencies. Attends and actively participates in interdepartmental meetings/education/competencies. Actively participates by giving constructive input. Adhere to policies, procedures, and guidelines consistently. Participates in the development and attainment of departmental goals Foster a collaborative, team-oriented environment, supporting the overall function of CMC and the HIM department. Maintains a clean, safe working environment. Report any employee illness or injury according to policy. Assists in QI/QA as requested including data collection. Communicate effectively with team members and other departments to ensure smooth workflows. Complete assigned work with accuracy and within established timeframes.

Related Job Behaviors:

Integrity/Pride/Honor

: Exhibits the highest standards of professionalism in dealings with co-workers, employers, visitors, patients and residents both inside and outside of the facility.

Respect/Equality

: Treats others as he/she would like to be treated.

Communication

: Communicates openly and honestly and in a way that is clear and understandable. Uses positive communication and communicate appropriately with all CMH departments.

Compassion

: Creates an environment of safety and trust for patients/residents/employees

Trust

: Demonstrates trust in co-workers.

Professionalism

: Demonstrates honesty and integrity. Always strive to give 100%

Safety

: Creates/Ensures that work environment is safe for patients, residents, employees and visitors.

Fiscal Responsibility

: Is a good steward of CMH resources.

Ambassadorship

: Uses good judgement in behavior, appearance, words and actions. Remembers that employees are on stage at all times.

Quality

: Is proficient, competent and efficient.

Teamwork

: Lends a hand whenever possible to ensure top-notch patient/resident care.

Commitment

: Committed to co-workers, patients, residents and providers.

Work Environment:This job operates in a hospital setting. This role requires regular walking to various locations around the hospital. This role may come in contact with patients who may have contagious illnesses.

Required:

CPC or CCS certification within 18 months or hire.

Thorough knowledge of medical terminology, anatomy and physiology, pharmacology, and coding principals.

Ability to maintain focus on complex and detailed information. Ability to interact effectively with peers and managers. Ability to communicate clearly and effectively with hospital staff and physicians. Ability to handle multiple tasks and changing job assignments.

Preferred:

Experience in ICD and CPT coding. Working knowledge of DRG documentation and assignment

* Prior experience in a healthcare, particularly in a Health Information Management (HIM) department or medical records environment.