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Lexington Regional Health Center

Title: Medical Coder

Effective Date: October 29, 2021

Supervisor: Director of Health Information Management

Department: Health Information Management

FLSA Status: Non-Exempt

Principle duties and responsibilities

• Review medical records to assign accurate diagnostic and procedure codes to patient records, which will play a key role in determining reimbursement and adherence to coding compliance regulations and corporate policies developed to ensure accurate billing.
• Responsible for coding specific areas of the organization as assigned. May have the potential to transition to a work from home position based on the needs of the organization after on- site orientation and training has been established.
• Use of encoder software to assign appropriate CPT and ICD-10-CM/PCS codes.
• Collaborate with the various departments to ensure proper charging and billing for maximum reimbursement.
• Interact with providers regarding documentation and selection of procedure codes and Evaluation/Management levels.
• Participate in continuing education activities to enhance knowledge and skills and maintain credentials.
• Work in collaboration with other Health Information Management employees to collaborate workflow.
• Ensure patients and visitors follow current infection control guidelines.
• Responsible for ensuring the environment meets appropriate governing body standards.
• Duties that could include blood exposure and risk to bloodborne pathogens (eg: lacerations, handling of blood-contaminated items, etc.)
• Maintains patient and staff safety through the use of patient safety tools (Teamstepps, Just Culture, etc.).
• Regular attendance at the assigned work location is required.
• Performs all other duties as assigned.

Minimum knowledge, skills, and abilities

• Ability to read, analyze, and interpret reports, general business directives, policy and procedure statements, and governmental regulations. Ability to use standard office equipment and computer software proficiently. This is typically acquired through the completion of a high school diploma or equivalent.
• AHIMA, AAPC, RHIA, or RHIT credentials preferred but not required. Minimum of 2 years previous coding experience required. Will consider education in a qualified coding program in lieu of credentials or previous experience.
• Ability to complete reports and correspondence at a professional level.
• Ability to maintain strict confidentiality with regard to protected and sensitive information.
• Ability to solve problems independently and confidently by applying analytical and logical thinking.
• Ability to immediately respond to common inquiries and complaints from patients, employees and regulatory agencies.
• Ability to effectively communicate with individuals from diverse backgrounds.
• Ability to effectively organize and present information and respond to questions from employees and external groups of varying sizes.
• Successful completion of required knowledge and training of standard precaution protocols and when to apply during principle duties and responsibilities.

Working conditions

• Works in a normal office environment, well lighted and ventilated with minimal exposure to excessive noise, dust, temperature, etc.
• Subject to frequent interruptions.
• Requires auditory ability sufficient to hear the telephone with typical hearing-impaired enhancements and to hear normal conversations typical in an office setting.
• Requires vision sufficient enough to read a computer screen with typical vision-impaired enhancements and to read entries made into the medical record.
• Requires significant time at a desk both writing and on a computer, up to 90% of work time. Requires fine motor coordination 70% of work time. Workers are required to transport up to 8 pound stacks of paper to be placed on various shelf heights, from 13 inches from floor, up to 73 inches from floor 5% of work time. Workers are required to remove a shred paper bag from its enclosure, which weighs up to 90 pounds, and requires 2 people to remove and transport the bag 15 feet; this is completed approximately 1 time per month.

Management responsibilities

1. None

Job description statements are intended to describe the general nature and level of work being performed by employees assigned to this job title. They are not intended to be a complete list of all responsibilities, duties, and skills required.