Medical Records Tech

Department: HIM Coding

Schedule: Per diem

Shift: Rotating Shifts

Hours: PRN, hours determined by the department

Job Description:

• High School Diploma/GED
• Minimum of 1 year of experience
• SUMMARY: This is a non-certified specialized position for coding, analyzing, and summarizing data from the medical record, using AHA national and hospital specific guidelines. Assigns and sequences ICD-9 diagnoses and procedures and CPT codes when indicated for inpatient medical records. Assigns and validates APR/ DRG assignment for case mix.
  Principle Duties and Responsibilities:
  
  • Reads the medical record to identify and translate diagnoses and procedures into codes using the current version of ICD-9-CM & CPT.
  
  • Assigns APR/DRG and selects appropriate secondary diagnoses for severity of illness (95% accuracy)
  
  • Maintains current Productivity Standards (1 super complex, 2 complex or 3 routine per hour)
  
  • Queries physicians to clarify documentation of diagnoses and procedures to ensure complete and accurate coding.
  
  • Abstracts medical records and reviews data elements required for reporting to HSCRC to ensure accuracy (98% accuracy).
  
  • Performs any additional duties as assigned.
  
  • Participates in department/section meetings.
  
  • Attends/completes educational requirements in order to maintain coding proficiency.
  
  • Maintains current knowledge of all new regulations and coding changes.
  To provide for the well-being of our patients, visitors, and staff, St. Agnes HealthCare requires that all prospective employees pass a criminal background check and drug/alcohol screening.

High school.  Completion of Medical Terminology, Anatomy & Physiology courses.

Completion of ICD-9-cm, CPT coding courses.

 

Required Experience: A minimum of 1 years acute care inpatient coding/outpatient surgery experience