Coder II

DEPARTMENT: CODING

F ACILITY: Tift Regional Medical Center

WORK TYPE: Full Time

S HIFT: Daytime

SUMMARY

Under the supervision of the Coding Supervisors and Manager, the Coder II assigns codes to discharge records for inpatients, outpatients and emergency room patients based on diagnoses and operative procedures.

RESPONSIBILITIES

• Selection/sequencing of principal and secondary diagnosis done correctly at least 98% of the time.
• Uses manual or computer encoder for appropriate coding system (ICD-9-CM or CPT) to assign code to completely describe physician documentation of diagnosis or procedure.
• If diagnosis is unclear, contacts documentation specialists for query.
• Ensures corrections made by physician and other medical personnel are properly recorded and complete.
• Enters coded information in computer system for billing purposes.
• Meets minimum standard of 98% productivity requirements.
• Assists case managers in coding and reimbursement issues.
• Abstracts designated statistical data from patient record and enters the information into the abstract database.
• Abstracts all appropriate data at least 98% of the time.
• Releases confidential information only in accordance with hospital policy.
• Assures security of departmental files in accordance with departmental policy.
• Codes records according to industry standards without regard to reimbursement.
• Knows emergency procedures for fire, safety, hazardous material utility system failure, and disasters.
• Keeps abreast of pertinent federal, and state regulations and laws and Tift Regional Health System, Inc. (“TRHS”) policies as they presently exist and as they change or are modified.
• Understands and adheres to: TRHS’ compliance standards as they appear in TRHS’s Corporate Compliance Policy, Code of Conduct and Conflict of Interest Policy; and HIPAA and TRHS policies regarding privacy and security of protected health information.
• Demonstrates the ability to perform tasks that meet the age-specific requirements of the persons, patients, vendors, and staff that the employee is charged to interact with as required by the position.
• Offers suggestions on ways to improve operations of department and reduce costs.
• Attends all mandatory education programs.
• Improves self-knowledge through voluntarily attending continuing education/certification classes.
• Maintains required competency levels as identified in written exams, skills checklists, skills labs, annual safety and health requirements as well as service excellence education hours requirements.
• Cross-trains in order to better assist co-workers and to provide maximum efficiency in the department.
• Volunteers/participates on hospital committees, functions, and department projects.
• Manages resources effectively.
• Reports equipment in need of repair in order to extend life of equipment and removes malfunctioning equipment out of service with timely reporting to the appropriate personnel.
• Makes good use of time so as to not create needless overtime.

EDUCATION

• High School Diploma or Equivalent

CREDENTIALS

• Certified Coding Associate
• Certified Professional Coder
• REGISTERED HEALTH INFORMATION TECHNOLOGIST
• Certified Coding Specialist
• REGISTERED HEALTH INFORMATION ADMINISTRATOR

OTHER INFORMATION:

In addition to high school diploma or equivalent, Certified Coding Associate (CCA), Certified Professional Coder (CPC), or Registered Health Information Technologist (RHIT) credential is required. At least 2 years of coding experience is preferred. A score of 85% or higher on internal coding test required.

Southwell/Tift Regional Health System, Inc. is an Equal Opportunity Employer.