Medical Coder (On-site) - Health Information Management

Job Duties

• Identify specific clinical findings, support existing diagnoses, or substantiate listing additional diagnoses in the health record based on thorough knowledge of medical terminology and abbreviations; anatomy and physiology; major disease processes; and pharmacology.
• Correlate pharmacy, laboratory, radiology treatments and results with diagnoses.
• Apply extensive knowledge of coding conventions and rules established by the American Medical Association (AMA) and the Health Care Finance Administration (HCFA) for assignment of diagnostic and procedural codes.
• Show extensive knowledge of classification systems and references such as the International Classification of Diseases (ICD), Diagnostic Related Groups (DRGs), Ambulatory Patient Classifications (APCs), and Current Procedural Terminology (CPT).
• Utilize Health Information Management theory, principles, practices, techniques, concepts, and policies to analyze the health record and participate in performance improvement activities.
• Understand and apply medico-legal aspects of health information management.
• Comply with the Privacy Act of 1974 regulations and requirements related to patient confidentiality.
• Adhere to JCAHO, HCFA, Medicare/Medicaid, Office of Inspector General, and Wind River Family and Community Health Care policies to ensure the health record complies with regulatory requirements.
• Initiate and follow through with assignments using established policies, instructions, and accepted practices in Health Information Management.
• Analyze health information using basic knowledge of quantitative and qualitative processes.
• Data collection, compilation, and organization of information from reporting and presentations.
• Use Performance Improvement methodology to track, trend, recommend resolutions, and report status of adverse or quality service.
• Communicate effectively through oral communication skills to conduct briefings and consultations with ancillary, clinical, and medical providers.
• Utilize computer skills to sufficiently abstract data and review/complete the health record.
• Maintain national coding certification through the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA).
• Maintain a good working relationship within the Health Information Management department and with other departments.

Qualifications

• Thorough knowledge of medical terminology and abbreviations; anatomy and physiology; major disease processes; and pharmacology.
• Extensive knowledge of coding conventions and rules established by the American Medical Association (AMA) and the Health Care Finance Administration (HCFA).
• Extensive knowledge of classification systems and references such as the International Classification of Diseases (ICD), Diagnostic Related Groups (DRGs), Ambulatory Patient Classifications (APCs), and Current Procedural Terminology (CPT).
• Knowledge of Health Information Management theory, practices, techniques, concepts, and policies.
• Thorough knowledge of medico-legal aspects of health information management.
• Thorough knowledge of the Privacy Act of 1974 regulations and requirements.
• Thorough knowledge of the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.
• Knowledge of JCAHO, HCFA, Medicare/Medicaid, Office of Inspector General, and Wind River Family and Community Health Care policies.
• Ability to initiate and follow through with assignments using established policies, instructions, and accepted practices in Health Information Management.
• Basic knowledge of quantitative and qualitative processes to analyze health information.
• Basic knowledge of Performance Improvement methodology.
• Oral communication skills to conduct briefings and consultation with ancillary, clinical and medical providers.
• Computer skills to sufficiently abstract data and review/complete the health record.
• Maintain national coding certification through the American Academy of Professional Coders (AAPC) or the American Health Information Management Association (AHIMA).
• Maintain a good working relationship within the Health Information Management department and with other departments.