Credentialed Coder

Newman Regional Health

Job Description:

Analyzes, assembles, codes, and abstracts in-patient medical records to produce accurate patient billing; for disease, operation and physician indices; statistical research or other information.

Analyzing, assembling, coding, and abstracting:

  • Codes accurately and in a timely manner all diagnoses and procedures from discharge records using ICD-9-CM methodology and UHDDS guidelines with 95% accuracy rate and maintains a current record of those charts coded and those to be coded using a copy of the daily discharge list and pending transfer list.
  • Abstracts information from all charts onto computer with a 95% accuracy rate per month and maintains a current record of those charts abstracted. Bring copies of studies within last 12 months to review.
  • Contacts physicians when explanation or clarification is needed for proper coding upon receipt of chart needing additional information. Utilizes 3M optimization features to optimize/analyze DRG assignments.
  • Prints coding summary, updates deficiency list, and routes charts to physician’s incomplete file on a daily basis.
  • Complies with accrediting agencies, KFMC, and other regulatory agencies with regards to chart requirements and maintains record of requirements and changes.
  • Monitors incomplete patient records to assure all records are coded by the 20th of the following month. Generates unbilled report to monitor incomplete abstracts and reconciles by the 20th of the following month. ______ of last 12 months were closed by the 20th of the following month.  If less than 80%, please describe action plan to achieve 80%.
  • Demonstrates a thorough knowledge of coding principles.
  • Accurately identifies deficiencies and generate deficiency list for each record.
  • Maintains notebooks of coding updates required by specific payors to ensure proper reimbursement. (Review with Operations Manager at time of evaluation).
  • Seeks to increase knowledge of coding guidelines by reading literature and coding clinics.

Blue Cross/Blue Shield of Kansas Abstracting:

  • Abstracts Blue Cross charts as per KHDS protocol.
  • Attend exit conference when BC/BS field representative is on-site for audit.

Medical Record Review:

  • Attend Medical Record Review staff meetings which are held every six months to review audit procedures and ensure continuing compliance.
  • Review six medical records each month using the Medical Record Review Summary sheet.

72 Hour Medicare Rule:

  • Runs the Medicare 72 hour rule report on a daily basis, evaluates and informs others of which accounts need to be combined.

Computer Maintenance:

  • Follows care instructions for Meditech computer.
  • Maintains software updates and serves as contact person for Meditech and 3M report.
  • Maintains Meditech Dictionaries assigned to the HIM Department.

Other Duties and Responsibilities:

  • Accurately enters OBS hours/charges on all observation patient charts that were admitted directly to acute within 5 days of discharge from acute.
  • Works and communicates in a positive and cooperative manner with management and supervisory staff, medical staff, co-workers and other health care personnel, and patients and their families when providing information and services, seeking assistance and clarification, and resolving problems.
  • Maintains established department policies, procedures, objectives, quality assurance, safety, environmental and infection control policies.
  • Accurately resolves deficiencies and re-analyzes medical records.
    • Completes Performance Improvement/Compliance audits as required.
    • Serves as HIM Representative on Charge Audit Committee.
  • I have read signed the Code of Conduct and AHIMA code of ethics. I have received ___ hours of coding education. I have read all coding clinics and CPT assistant updates to date.

Other Duties Shared by all HIM Employees:

  • Is responsible for proper body mechanics, lifting and desk procedure. (Describe how you maintain proper desk posture.)
  • Do you wear your hospital ID Badge?
  • What does RACE stand for?
  • Personal Productivity – Demonstrates a high level of productivity. (Describe how you meet this.)

Regular and timely attendance:

  • Adheres to Employee Health Policies (Illness Report, TB Skin Test, etc.). Do you complete Illness Report when you return to work? Do you notify Operations Manager and other staff of illness? Do you keep Operations Manager informed of need for sick leave?
  • Use of benefit time.
  • Dependability – Completes projects and tasks in expected time frame. (Give examples.)
  • Continually evaluates the departments’ quality of services and offers suggestions for improvement. (Describe suggestions you have offered in the last year.)
  • Participation in organizational activities is encouraged. (Describe your participation -United Way, Health Fair, etc.)
  • Demonstrates effective communication, internal and external, both verbal and non-verbal with:
    • Immediate work group
    • Extended health care team
    • Patient, family and visitors
    • Phone etiquette


  • Uses departmental and organizational key words and phrases in communication with customers.
  • Communicate information which would affect another’s work. Ensure continuity of care by reporting to next care provider.
  • Answers phone calls promptly. Identifies myself and my department.  Provide correct number before transferring calls.  Thank the caller for holding.
  • I handle conflicts with co-workers and other departments in a cooperative manner, involving my supervisor when needed.

Policies and Procedures:

  • I am aware of and will adhere to all hospital policies, procedure, and standards of practice including Legal Compliance, HIPAA, Safety, Infection Control and Employee Health.
  • I read payroll stuffers, pulse articles, bulletin boards, e-mails and departmental communications to keep myself informed of changes in polices and procedures.
  • I take responsibility to start and stop my work day as scheduled, or as requested by my supervisor.
  • I abide by the attendance policy of not missing more than 5% of my worked time and/or not establishing a pattern of missing work.
  • I prioritize and organize my work to be as efficient as possible during my day.
  • Responsibilities / Accountability for Money, Equipment, etc.
  • Responsible for the care and usage of departmental equipment.
  • Responsible for those supplies utilized in the department for appropriate use to assure minimal waste.

Required Qualifications:

  • Associates degree or baccalaureate degree in HIM or related filed
  • RHIT or RHIA credentials or Certified Coding Specialist preferred.
  • Experience in ICD-10-CM/PCS, CPT and HCPCS coding

Preferred Qualifications:

Two years previous medical record experience in coding and analysis preferred.

Education Qualifications:

Associates degree or baccalaureate degree in HIM or related filed

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