The Certified Medical Coder, under the direction of the Health Care Administrator, performs data key-entry and verification of all Patient Care Component data elements into the Patient Care Component (PCC) of the Resource and Patient Management System (RPMS). This position will perform ICD-10-CM, CPT and HCPCS coding for reimbursement. Responsible for quarterly auditing of the primary care providers documentation. This includes a wide range of health care data resulting from outpatient, lab, x-ray, pharmacy, optical, behavioral health, dental and physical therapy visits at the Sault Tribal Health Center.
ESSENTIAL FUNCTIONS: (includes, but is not limited to, the following)
- Assigns diagnosis and procedure codes by reviewing health records/information to ascertain all appropriate diagnosis and/or procedure codes
- Abstracts and enters clinical data from the medical record into RPMS
- Concurrently reviews and interprets medical records documentation in both hard copy and computerized formats to determine the most accurate diagnosis and procedures for specific visits
- Determines principal diagnosis and procedure and properly sequences all secondary diagnoses.
- Validates and merges all complex ancillary service data to identify orphan visits for lab, radiology and pharmacy.
- Corresponds with medical staff and other providers regarding records with omissions and/or inconsistencies to ensure timely completion.
- Audits documentation for benchmarking, quality assessment or other studies.
ADDITIONAL RESPONSIBILITIES: (includes, but is not limited to, the following)
- All other job related duties as assigned.
CONTACTS: Internal contacts occur on a regular basis with departmental personnel. Immediate peers, peers in other departments, immediate supervisor/manager, managers in other departments, customers, outside vendor/service providers.
Position light with lifting of 20 pounds and frequent lifting/carrying up to 10 pounds, Physical factors include constant use of near/midrange/far vision, depth perception, color/field of vision; frequent standing, walking, sitting, pushing/pulling, stooping, kneeling, reaching, manual handling, use of hearing; occasional crawling and use of smell. Working conditions include constant exposure to medical office environment. Potential hazards include constant computer use; frequent patient contact, occasional exposure to moving mechanical parts, high exposed places, infectious exposure, needles/syringes and equipment.
Education: High School Diploma or GED required.
Experience: 1 year experience in a medical coding setting using ICD-10-CM required.
Certification/License: ICD-10-CM certified, CCS, CCS-P, or CPC certification is required. Must maintain certification. Will be required to undergo and successfully pass a background check. Must maintain a good moral character standing. Will be required to complete and pass pre-employment drug testing.
Knowledge, Skills and Abilities: Thorough knowledge of medical terminology including prefixes, suffixes, standard abbreviations, and pharmaceutical terminology. Knowledge of anatomy and physiology and major anatomical symptoms. Knowledge of ICD-10-CM and CPT codes. Ability to interpret the ancillary data to appropriately connect and merge with the patient’s visit to complete the encounter information. Skill in using a computer for analyzing encounters and notifying providers of data that needs corrections through EHR broadcast, notifications and templates. Ability to use medical references independently. Knowledge and skill sufficient to decipher terminology used by providers in EHR. Must maintain confidentiality.