Medical Records Manager/Coder - ARH Advanced Care, Inc.

Overview

The Medical Records Manager/Coder is responsible for the administration of medical record services as well as hospital audits, abstracts, and coding patient’s medical records in accordance with established numerical coding systems and special hospital coding systems.

Responsibilities

MAJOR ACTIVITIES

· Ensures the prompt completion, filing and retrieval of medical records.

· Ensures that each patient’s confidentiality is preserved at all times.

· Assists in the maintenance of a complete and accurate clinical database for the purpose of statistical reporting and compliance.

· Ensures documentation is legible, dated, authenticated and recorded in ink, typewritten or recorded electronically.

· Addresses record requests.

· Audits, abstracts and codes medical and related data from patients in medical records with routine diagnosis, surgical and medical procedures, in accordance with regulatory agencies and hospital codes.

· Reviews narrative records of patient treatments and surgical procedures to determine what information is appropriate for coding purposes, and prepares case abstracts.

· Enters coded medical records data on computer terminal; selects diagnosis and operations codes from computer designated abstracting system.

· Checks patients’ medical files for completeness, consistency, and compliance with hospital regulations, assuring that all relevant medical records are included in each patient’s file.

· Contact physicians, nurses, laboratory, and other auxiliary personnel for information needed to complete, correct, or clarify medical records, and to resolve discrepancies.

· Ascertains that cases of communicable disease discovered at the hospital are reported to the Health Department, preparing and forwarding the necessary documents when required.

· Checks patients; medical files for completeness, consistency and compliance with hospital regulations assuring that all relevant medical records are included in each patients’ file.

· Maintains special registries and records, abstracting and summarizing medical data from patient’s files.

· Participate in committee meetings as requested. ·

Performs other related duties as needed in order to support the achievement of department goals and objectives.

SPECIFIC ACCOUNTABILITIES:

· Accountable for coding, abstracting and auditing patient’s medical records in accordance with established numerical coding systems and hospital codes.

· Accountable for assuring patient’s medical files are complete, consistent, and comply with hospital regulations.

· Accountable for entering coded medical records data on computer terminal; select diagnosis and operations codes from computer designated abstracting system.

Performs all duties as relevant and appropriate to the position.

Qualifications

Education

· Must have either a 2-year associate’s degree as a Registered Health Information Technician (RHIT) or a Registered Health Information Administrator (RHIA) 4-year bachelor’s degree.

· Satisfactory completion of an approved academic curriculum and Certification as a Coder

Required Skills, Knowledge, and Abilities

· Two years of experience in hospital medical records department. Experience in long term acute care hospital preferred.

· Must possess strong computer skills.

· Must possess effective interpersonal communication skills and have proven cooperative work relationships with physicians.