What are the responsibilities and job description for the CODER II, MEDICAL RECORDS position at South Georgia Medical Center?
Description
Location: Main Campus
Department: MEDICAL RECORDS
Schedule: Full Time, 8 HR Day Shift,
POSITION SUMMARY:
Analyzes inpatient and; outpatient medical records to assign both ICD-10 and CPT codes to diagnoses and procedures. Abstracts pertinent information into hospital information system. Primarily codes all inpatient visits As needed codes outpatient visits including Emergency, Outpatient Surgery, Observations and various clinics. Uses 3M encoder and grouper as well as verifies codes in books. Maintain a productivity log daily. The coder may interact with physicians as well as other health professionals to confirm documentation in the medical record. Maintains a minimum 98% accuracy and 95% productivity rate.
KNOWLEDGE, SKILLS & ABILITIES:
- Associates Degree from a certified health information technology program preferred with certification as an RHIT preferred.
- Certified Coding Specialist preferred but not required.
- Requires knowledge of anatomy and physiology, medical terminology, ICD-10 and CPT coding.
- Minimum one year inpatient coding experience preferred, outpatient coding experience considered.
- Flexibility in scheduling.
- Analytical with attention to detail while maintaining ability to make decisions based on available documentation.
- Typing skills for use of computer keyboard.
- Professional communication skills for dealing with physicians and other hospital staff
WORKING CONDITIONS- ADA INFORMATION:
Coder will spend long hours working at a computer terminal. Must be able to see and read names, numbers, and colors. Must be able to withstand high stress levels to meet turnaround times while maintaining accuracy. Must have ability to accurately adjust to using 3 information systems simultaneously, 3M Encoder, Series and HPF record imaging system.
