SHSMD Career Center

Medical Coder is responsible for ensuring accurate, complete and timely coding of all professional services.

NON-EXEMPT

Ensures that records are coded within 48 hours of completion of dictation, excluding weekends and holidays.

Reviews documentation for completion and accuracy to ensure proper assignment of CPT, ICD-10 CM and HCPCS codes and modifiers.

Contacts responsible physician in a professional, tactful manner, if diagnosis is not available on medical record.

Codes diagnoses and procedures from clinical summary in partnership/communication via the BMG escalation process with physician's involvement.

Refers to manager of physician coding , If there is a question regarding the diagnoses/codes.

Utilizes computerized coding/abstracting equipment.

Codes all diagnoses/procedures in accordance to ICD-10-CM coding principles and the Coding Manual.

Track and Trend provider coding variances and report to physician coding manager.

Meets quality standards of having 95% of principal diagnoses and procedures appropriately and/or correctly coded.

Maintains 95% rate of information correctly abstracted.

Reviews coding periodicals within seven (7) days of receipt.

Notifies manager whenever work is more than 48 hours behind work deadline.

Assists the manager with state requirements and reports.

Acts as a resource person to BMG staff and physicians for coding and may provide education regarding coding changes/issues.

Must be familiar with all medical record and coding billing requirements.

Maintains a good working relationship within the department, other departments and medical staff.

Willing to accept additional assignments.

Performs performance improvement functions through data collection and documentation review.

Demonstrates the ability to deal with pressure to meet deadlines, to be accurate, and to handle constantly changing situations.

Demonstrates the ability to deal with a variety of people, deal with stressful situations, and handle conflict.