Coder - Medical Records - 40 hrs/weeks (Days)
At Steward Health Care System, we are committed to improving the health of our communities by delivering exceptional, personalized behavioral health care with dignity, compassion, and respect. Our continued focus on the patient experience informs our caregivers in how to provide care that is respectful of and responsive to individual patient and family preferences, needs and values.
We dedicate ourselves in the communities we serve to delivering affordable health care to all and being responsible partners. No matter what your role, as a member of the Steward family, you are a specialist in the making every patient and family feel right at home, every co-worker a key to our success, and every referring practice, a team of prized colleagues.
In support of this, we commit ourselves to the following values:
If you are seeking a fast-paced, challenging position in an organization committed to achieving and maintaining a standard of excellence in all we do, our organization may be a good fit for you.
I. Position Function:
Code and abstract the diagnostic, demographic, and procedure information of St. Elizabeth's
Utilize coding software to insure accuracy of coded information and to insure optimal reimbursement.
II. Job Relationships:
Supervised and reportable to the following, by job category:
- Supervisor of Coding
Must be able to collaborate and communicate effectively with the Medical staff and various Hospital personnel.
To select the diagnoses and, if any, procedures to be coded from an inpatient stay or outpatient encounter, utilizing ICD-9-CM and CPT-4 coding systems.
To assist various hospital personnel in selecting an ICD-9 or CPT-4 code.
IV. A. Responsibilities/Essential Functions:
1.) "Provides superior customer service to internal and external clients, customers,
and patients as referenced in the Service Excellence Standards."
Code inpatient medical records using the ID-9-CM coding system in a high quality manner, achieving the required productivity.
Abstract demographic information from the medical record for data reporting requirements.
Input coded information into the UIS system in a productive, high quality manner, utilizing edits, optimizer, re-sequencing and encoder features with appropriate.
Utilize the CPT-4 coding system in a high quality manner for outpatient procedures, on all payer types.
Maximize DRG reimbursement through the effective use of the Grouper and extensive knowledge of coding policies and procedures.
Assist health care personnel and the Medical staff in developing data bases for study.
Act as a resource to the Hospital and Medical staff for coding, DRG and information regarding third party denials.
B. Responsibilities/Non-Essential Functions:
Interact with the Medical Record Department and assist personnel from that department as necessary.
Further the art of coding through field related education.
Perform additional duties as required.
V. Reporting Requirements:
Reports immediately to the Coding Supervisor any problems or questions regarding the coding or abstracting of a medical record.
Reports to the Coding Supervisor, who serves as the immediate supervisor, situations requiring the supervisor's attention.
Reports productivity and quality improvement forms as directed.
Shall be accountable and responsible for accurate and timely coding and abstracting of inpatient and outpatient data, utilizing ICD-9-CM and CPT-4 coding systems.
Shall be accountable for abiding by all coding guidelines, including interdepartmental and the
Shall be accountable for completing monthly quality improvement forms and submitting to Coding Supervisor by the end of each month.
Shall be accountable for observing all policies and procedures of the Department, including Hospital-wide confidentiality policies.
Associate degree from an accredited record technician program or a bachelor degree from a registered record program preferred.
Education in health, science, disease, medical terminology, anatomy and physiology.
1-3 years inpatient and some CPT-4 outpatient coding experience in an acute teaching hospital setting.
ICD-9-CM and CPT-4 coding skills.
Interpersonal and communication skills sufficient to satisfactorily communicate with Medical staff and various Hospital personnel.
Accredited Record Technician, Coding Certified Specialist, or Registered Record Administrator preferred.
Hospital specific coding software.
Computer literate, including use of groupers, optimizers and encoders.
Important COVID message
Please note, St. Elizabeth's Medical Center is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment - with confidence and without fear. Our Safe and Ready program consists of a rigorous [five-point] standard ensuring patient safety, confidence, and convenience: Expanded hours will allow previously cancelled procedures to be scheduled as quickly as possible. Any COVID-19 related care takes place in designated areas away from other patients and their families. Emergency Departments are reorganized to be a safe place to treat all emergency patients. A stringent cleaning policy has been implemented throughout the hospital. A strictly controlled visitor and masking policy is required for patient safety. You can rest assured that we have made the necessary preparations to provide care in a safe, controlled, and professional way.