Medical Records Coding Technician abstracts clinical information from medical records and assigns the appropriate ICD or CPT codes using industry-standard coding guidelines. Assigns required DRG (diagnosis-related grouping) codes. Being a Medical Records Coding Technician works with coding databases and software to input and maintain data according to standard procedures. Performs quality audits of work. Additionally, Medical Records Coding Technician maintains and up-to-date knowledge of coding and documentation requirements. Requires a medical coding certification. The exact type of coding certification may vary based on the clinical setting or a medical specialty focus. May require an associate degree. The AAPC Certified Professional Coder (CPC) certification is typically required. The Certified Coding Specialist (CCS) certification is also a typical requirement. Typically reports to a supervisor or manager. The Medical Records Coding Technician works independently within established procedures associated with the specific job function. Has gained proficiency in multiple competencies relevant to the job. To be a Medical Records Coding Technician typically requires 3-5 years of related experience. (Copyright 2024 Salary.com)
SUMMARY: Performs all the general clerical duties including pulling; searching for charts for appointments, patient related issues, filing, retrieving, scanning, purging and answering phone calls. Also responsible for filling medical records requests. Responsible for scanning documents to the Electronic Health Record (EHR) and for purging information once confirmed in EHR.
QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential function satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE: High school diploma or general education degree (GED) or one to three months’ related experience and/or training; or equivalent combination of education and experience required.
CERTIFICATES, LICENSES, AND REGISTRATIONS: None.
LANGUAGE SKILLS: Ability to read comprehend simple instructions, short correspondence, memos, and to write correspondence. Ability to effectively present information in one-on-one and small group situations to customers, and other employees of the organization.
REASONING ABILITY: Ability to apply common sense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to deal with problems involving several concrete variables in standardized situations.
PHYSICAL DEMANDS AND WORK ENVIRONMENT: The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with a disability to perform the essential functions.
While performing duties of job, employee is occasionally required to stand; walk; sit; use finger, handle, or feel objects tools, or controls reach with hands and arms; talk and hear. Employee must occasionally lift and or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception and the ability to focus.
ADA: The employer will make reasonable accommodations in compliance with the Americans with Disabilities Act of 1990. This job description will be reviewed periodically as duties and responsibilities change with business necessity.
WORK ENVIRONMENT: The noise level in the work environment is usually moderate.
Essential functions are those tasks, duties and responsibilities that comprise the means of accomplishing the job’s purpose and objectives. Essential functions are critical or fundamental to the performance of the job. They are the major functions for which the person in the job is held accountable. Note: (other duties may be assigned, deleted or changed at any time, at the discretion of management, formally, or informally, either verbally or in writing).
OTHER RESPONSBILITIES:
2. Quantity - Meet the quantitative performance standards. Consistently meets deadlines.
3. Quality - Make the creation of accurate, thorough and appropriate work products a priority. Take pride in work.
4. Planning/Organization - Anticipate and set priorities to support business needs: adapt strategies, policies and procedures for achieving them: manage and measure achievements.
5. Problem Solving/Decision Making - Identify and analyze problems: take action to resolve; apply sound judgment and take ownership for their resolution.
6. Communication - As set forth in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) maintain Patient Confidentially in accordance with State and Federal Regulations. Inform and influence others by clear and concise expression of ideas and information in oral and written forms. Demonstrate effective listening skills.
7. Working with Others - Fosters an environment that nurtures collaboration, teamwork, and mutual respect through effective communication, and demonstrates positive communication skills evidenced by effective and cooperative working relationships with peers.
8. Responsibility - Maintains flexibility and accepts job assignments willingly. Accepts responsibility for compliance (Code of Conduct) with company rules and regulations. Takes positive actions to meet job responsibilities.
9. Leadership - Demonstrate commitment through behavior to the organizations values. Encourage team and peers to embrace those values. Set an example.
10. Customer Focus - Take ownership to identify and meet external and internal customer expectations. Make decisions, prioritize and carry out daily responsibilities accordingly. Acts with a sense of urgency. Displays AIDET: Acknowledge, Introduce, Duration, Explanation, and Thank you with customer interaction.
11. Dependability - Arrive and start to work on time. Attend meetings as scheduled. Absent within company guidelines.
12. Safety - Complies with all clinic safety and injury prevention policies and regulations. Adheres to safe work practice in order to prevent work-related injury and illness by participating and completing safety training requirements, using proper body mechanics at all times. Follows proper procedures during various emergency response and safety drills and responds to unusual occurrences affecting patients, visitors, employees, practitioners, contractors, patient property, or clinic property or facilities. Adhere to Incident Report Process for adverse patient event(s).