The Medical Records Manager/Coder is responsible for the administration of medical record services as well as hospital audits, abstracts, and coding patients 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 patients 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 patients 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 patients 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 patients medical records in accordance with established numerical coding systems and hospital codes.
Accountable for assuring patients 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 associates degree as a Registered Health Information Technician (RHIT) or a Registered Health Information Administrator (RHIA) 4-year bachelors 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.
...Buscamos un conserjeque cuide el edificio y lleve a cabo tareas de limpieza, mantenimiento y seguridad. El objetivo es mantener nuestro edificio limpio y ordenado. Responsabilidades Limpiar y suministrar reas designadas del edificio (limpiar el polvo,...
...to you!! Job Title: Records associate Location: Temple, TX - on-site Pay: $20-21/hr BOE Schedule: Monday - Friday: 8:00 AM 5:00 PM Job Description: Review medical records to determine if they should be retained or discarded Retrieve...
...to comfortably lift 30 lbs Able to stand for duration of shift Legally authorized to work in the U.S. Must be at least 16 years old Reliable transportation Must work at least 3 shifts per week for a minimum of 18 hours per week Responsibilities:: Cashier...
...helping families find the right insurance coverage? We are seeking... ...our team as Remote Insurance Agents. No prior sales or insurance experience... ...from the comfort of your home. What We Offer:... ...180,000 per year. Flexible work schedule and the ability to work...
...innovative team as a Digital Travel and Marketing Coordinator, and embark on an exciting... ...Work from anywhere in the world. No Experience needed (but could be useful)... ...our travel services. Manage your social media, create engaging content, and interact...