JOB SUMMARY

Codes, analyzes, and abstracts all scanned or imaged inpatient electronic medical records according to established classification system and enters the abstracted information into the hospital financial system via a CRT. Identifies documents of poor quality. Ensures all scanned documents are positioned correctly. Identifies the documents that are incorrect. Ensures each document is indexed to the correct patient/encounter. Refers identified issues to appropriate scanning/QC staff for correction.

The individual must be detailed oriented and be able to work independently. Must demonstrate initiative and ability to work with physicians and other healthcare providers with cooperation and flexibility. The team member has access to patient medical information, involved in ensuring the integrity of the legal medical record and must strictly uphold patient confidentiality. This position serves as a resource for other members of the organization in regards to code assignment issues and related policies and procedures regarding required documentation. Reviews assigned work queue(s) daily and ensure timely processing of assignments in each queue.

JOB QUALIFICATIONS

Education: Graduate of AHIMA accredited HIA or HIT program with completion of basic coding courses, required.Licensure: AHIMA or AAPC approved credential(s)- RHIT, RHIA, CCS, CPC, CCA or equivalent.

Experience: Minimum of three years experience in an acute care hospital.

Skills:

Knowledge of Medical Record content for inpatient discharges

• Knowledge of medical terminology, anatomy & physiology, DRG and POA assignment, and ICD10-CM/PCS coding systems

  • Ability to examine the chart and verify documentation needed for accurate code assignment

  • Good decision-making

  • Organized with attention to detail and quality

  • Ability to prioritize workload and strong recall and recognition skills

  • Ability to perform computer functions in Microsoft Windows

  • Good verbal, written and computer communication skills