LEAD HIM/MEDICAL RECORDS CODER

Responsibilities

• Provides guidance and workflow direction to all HIM staff in the Medical Records Department. Coordinates staffing issues and procedural issues with the Director of Health Information Management. Responds to inquiries of staff, vendors and the public for the purpose of providing information and /or direction, discussing and resolving any issues and/or problems related to the Medical Records Department in coordination with the Director of Health Information Management.
• Responsible for the assignment of diagnosis and/or procedure codes for all outpatient encounters, capturing the most accurate diagnosis and/or procedures with the greatest degree of accuracy and completeness.
• Review at a minimal, the following documents in order to assign the most accurate diagnosis and/or procedure codes for inpatient encounters:
• History and Physical (H&P)
• Psychiatric Evaluation
• All progress notes
• All physician’s orders
• Discharge Summary only if this would impact the DRG, for example: need for Complications and Comorbidities, etc.
• Consultation Report if indicated
• Assessment Department documentation
• Laboratory results, if order
• Nursing Discharge Note for patient that are transferred
• Medication
• Adheres to the Official Guidelines for Coding and Reporting, developed by the cooperating parties and documented in Coding Clinic for ICD-9-CM, published by the American Hospital Association.
• Adopts as evidenced by signature, AHIMA’s Standards of Ethical Coding. (See Attached)
• Use the Physician Query Form to obtain clarification from the attending physician on any coding questions, including the reference to source documentation.
• Assemble medical records at discharge.
• Analyze medical records at discharge.
• File medical records using terminal digit file.
• File documents in the medical record.
• Perform other duties as assigned.
• Support facility internal and external customer service standards.
• Follow Anchor Hospital Time and Attendance policy.
• Will adhere to all safety policies and safe work practices.
• Will adhere to all hospital policies and procedures.
  
  

Qualifications

Associates Degree or equivalent combination education and experience; Registered Health Information Technician, AHIMA or AAPC Coding Certification

About Universal Health Services

One of the nation’s largest and most respected providers of hospital and healthcare services, Universal Health Services, Inc. (UHS) has built an impressive record of achievement and performance. Growing steadily since its inception into an esteemed Fortune 500 corporation, annual revenues were $14.3 billion in 2023. During the year, UHS was again recognized as one of the World’s Most Admired Companies by Fortune; and listed in Forbes ranking of America’s Largest Public Companies.

Headquartered in King of Prussia, PA, UHS has approximately 96,700 employees and continues to grow through its subsidiaries. Operating acute care hospitals, behavioral health facilities, outpatient facilities and ambulatory care access points, an insurance offering, a physician network and various related services located all over the U.S. States, Washington, D.C., Puerto Rico and the United Kingdom. www.uhs.com

EEO Statement

All UHS subsidiaries are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants and teammates. UHS subsidiaries are equal opportunity employers and as such, openly support and fully commit to recruitment, selection, placement, promotion and compensation of individuals without regard to race, color, religion, age, sex (including pregnancy, gender identity, and sexual orientation), genetic information, national origin, disability status, protected veteran status or any other characteristic protected by federal, state or local laws.

We believe that diversity and inclusion among our teammates is critical to our success.

Avoid and Report Recruitment Scams

At UHS and all our subsidiaries, our Human Resources departments and recruiters are here to help prospective candidates by matching skill set and experience with the best possible career path at UHS and our subsidiaries. During the recruitment process, no recruiter or employee will request financial or personal information (e.g., Social Security Number, credit card or bank information, etc.) from you via email. Our recruiters will not email you from a public webmail client like Hotmail, Gmail, Yahoo Mail, etc.

If you suspect a fraudulent job posting or job-related email mentioning UHS or its subsidiaries, we encourage you to report such concerns to appropriate law enforcement. We encourage you to refer to legitimate UHS and UHS subsidiary career websites to verify job opportunities and not rely on unsolicited calls from recruiters.