Inpatient/Outpatient Coder/Abstracting Specialist

Administrative/ClericalHealth Information Management Dalton, Georgia


Description

Hamilton Health Care System, Inc.

Job Description and Performance Standards

Title:  Inpatient/Outpatient Coder/Abstracting Specialist 557985029

Department:  Health Information Management

Reports To:  Supervisor

Shift:  Varies

Status:  PRN

JOB SUMMARY

Codes, analyzes, and abstracts all scanned or imaged 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 those that are incorrect.  Ensures each document is indexed to the correct patient/encounter.  Refers identified issues to appropriate scanning/QC staff for correction. Position must be able to work in a team environment and be self-directed enough to work alone when necessary, with the opportunity to work remotely.

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 approved HIA or HIT program or equivalent, preferred.

Licensure:  RHIA, RHIT, CCS, CPC, CCA or equivalent.

Experience:  Three months to one year experience in an acute care hospital preferred.

Skills:  Knowledge of Medical Record content for inpatient and outpatient visits.

  • Knowledge of medical terminology, anatomy & physiology, DRG and APC assignment, and ICD9-CM, ICD10-CM/PCS & CPT coding systems
  • Ability to examine the chart and verify documentation needed for accurate code assignment.
  • Good decision-making.
  • Organized and 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.

 PHYSICAL, MENTAL, ENVIRONMENTAL AND WORKING CONDITIONS
Works in a typical office setting.  Frequent sitting, and long periods of reviewing records from a computer screen. Prolonged sitting and eye strain with concentrated effort over detail work.  Requires a moderate amount of working with computers.  Requires walking up and down stairs.  Requires use of proper body mechanics.  Often it will be necessary for individual to spend most of shift sitting.  Dexterity of upper extremities and fingers, as well as mental and visual dexterity to names, numbers, codes, report types, as well as hand dexterity to enter data.

i.    Work assignments require consistent periods of sitting.
ii.   Dexterity of upper extremities and fingers, as well as mental dexterity for utilizing dual monitors and operating multiple windows of different software programs simultaneously.
iii.  Ability to flex neck for reviewing documents on dual monitors.
iv.  Ability to communicate clearly and understandably on the telephone and in person.
V.  Ability to understand the spoken word on the telephone and in person.

WORKING CONDITIONS
This position must practice good organization skills due to interruptions and interactions with other team members.  Position must be able to work in a team environment and be self-directed enough to work alone when necessary.  Position must be able to work in a team environment and be self-directed enough to work alone when necessary, with the opportunity to work remotely. Must remain calm under stress and must be able to appropriately handle an irate person when the occasion arises (i.e., physician, hospital employee, patient).