Associate Medical Records Coder

Training program to learn all coding and abstracting duties to assure accurate completion of coding for all assigned patient records.

Job Responsibility

• Analyzes the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.
• Helps in selecting the principal diagnosis as documented in the medical record. Codes and reports diagnoses and procedures in accordance with the established guidelines.
• Reports a discharge disposition for all records as required and in accordance with the rules and regulations.
• Analyzes medical records for completeness of documentation and review the process on clarification for any incomplete/ambiguous or conflicting documentation. Understanding of the process for education of physicians and other clinicians by advocating proper documentation practices.
• Participates in required hospital education programs, as required.
• Maintains the minimum data standards for accuracy and productivity as defined by the facility.
• Completes all required homework assignments, virtual practicum, and exams for each module with a minimum passing grade as determined by leadership, as required.
• Completes modules regarding Medical Terminology, Anatomy & Physiology, Pathophysiology, Pharmacology, Reimbursement Essentials, ICDCM/PCS Coding, Health Insurance/Regulations in Health Care Coding, Introduction to Health Information Management & Data Content and Structure, Medical Records, as required.
• Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions.

Job Qualification

• Associate’s Degree required, or equivalent combination of education and related experience.
• Completion of a certified ICD 10 training course or graduation with a HIM degree (RHIA/RHIT program) and CCS or CPC-H preferred.
• 0-1 years of relevant experience, required.