POSITION TITLE: Medical Records Coder
RESPONSIBLE TO: Medical Records Director/Coding Supervisor
DATE: June 1, 2014
JOB SUMMARY: This is a special technical position that is accountable for
conversion of diagnoses and treatment procedures into codes using ICD-9 and
CPT and HCPCS. This position requires skill in the sequencing of
diagnoses/procedures to optimize reimbursement. Ensures that records are
coded in an accurate and timely manner. This position performs analysis and
coding of all medical records, including all hospital covered Specialty Clinics, i.e.
Oncology, Pulmonology, Pain Center, Rheumatology, OB/GYN, Internal
Medicine, Bone and Joint, Surgical Services, Western Missouri Family Health
Clinic-Holden, Western Missouri Family Health Clinic-Knob Noster. Office
charges are also entered into hospital systems for billing purposes.
WORKING CONDITIONS:
Pleasant environment subject to frequent interruptions.
Requires good visual acuity and manual dexterity.
Must be able to hear and verbally communicate with other staff including
physicians.
Must be able to sit for long periods of time.
Must be able to concentrate and complete detailed work in spite of frequent
interruptions.
Must be able to lift and move moderate weights.
Must have good mobility and stamina.
Must be able to twist, bend and reach occasionally.
KNOWLEDGE, SKILLS, EXPERIENCE REQUIRED:
 Coding credentials to be either RHIT, or RHIA, CCS, or AAPC
 AHIMA or AAPC member
 High school graduate or GED
 Knowledge of medical terminology and anatomy/physiology.
 Knowledge of ICD-9, CPT, and HCPCS coding
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Type accurately and be able to accurately input information/data into
computer
Detail-oriented and able to self-regulate varied tasks
Able to read and analyze medical record information
Able to understand and follow oral and written instructions
Able to prioritize work load
RELATIONSHIPS: Reports directly to Coding Supervisor and Medical Record
Department Director
PHYSICAL REQUIREMENTS:
Frequency Scale: 1 = Rarely/Never; 2 = Occasionally; 3 = Frequently and 4 = Consistently
Activity
1
Climbing
X
Hand-Eye
Coordination
Kneeling
2
3
4
Activity
X
- Loud
Commands or
Public
Speaking
X
Hearing
Pushing
X
- Normal
Conversations
Reaching
X
- Other
Sounds or
Auditory
Alarms
Vision
X
Sitting
Walking
Range of
Motion
3
4
X
- Acuity,
Near
- Acuity, Far
X
X
- Color Vision
Use of
Hands
Activity
1
2
3
4
Lifting
- Normal
Conversations
X
Stooping
2
Talking
Pulling
Standing
1
X
X
- Over 50#
X
- Over 25#
X
- Under 25#
X
X Memory
X
- Short term
X
- Long Term
X
X Analytical
Thinking
X Attention to
Detail
X Concentration
X
Decision
Making
X
X
X
- Arms
X
- General
Manual
Dexterity
- Shoulders
X - Keyboard
X Reading
X
X Writing
X
Skills or
Typing
AGE CATEGORIES OF INDIVIDUALS SERVED:
Demonstrates the knowledge and skills necessary to provide age-appropriate
care to the following patient population:
____Neonatal (1-30 days)
____Infants (30 days-1 year) ____Geriatric
____Adolescent (13-18 years)
____Adult (19-70 years)
(70+ yrs)
__x__No patient contact
____Children (1-12 years)
CORE DEPARTMENTAL COMPETENCIES- Consistently follows established Departmental, Human Resources and
Hospital Policies/Procedures
 Attends monthly medical record department meetings
 Wears Identification while on duty
 Uses computerized punch time system correctly
 Reports to work on time and as scheduled.
 Understands and demonstrates competency with equipment, to include
information technology, coding software, utilizes supplies and equipment
appropriately, to minimize waste and to include appropriate utilization of
time.
 Demonstrates behaviors which promote professionalism.
 Maintains and respects patient and employee privacy and confidentiality.
 Consistently codes accounts as assigned with accuracy (scoring as
follows)
To receive a 5 - 95 to 100% accuracy
To receive a 4 - 92 to 94% accuracy
To receive a 3 - 90 to 91% accuracy
To receive a 2 - 85 to 89% accuracy
To receive a 1 – Below 85% accuracy
 Assigns ICD-9, CPT and HCPC codes according to established mandated
coding guidelines for facility and professional coding
 Maintains coding credentials
 Maintains coding education to keep current on coding guidelines and
changes
 Demonstrates adherence to regulatory compliance plan
 Maintains and reports tumor registry, head and spinal registry, if
applicable.
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Assists co-workers as needed/requested
Maintains an effective rapport with all customers
Appropriately handles telephone and email communications with
customers
Supports the Medical Center’s Mission/Vision/Philosophy positively.
This is not necessarily an inclusive list of all responsibilities, skills, tasks,
requirements, efforts or working conditions associated with the job. While this is
intended to be an accurate reflection of the current job, management reserves
the right to modify essential functions of the job or to require that other or
different tasks be performed when circumstances change (i.e. emergencies,
changes in personnel, workload, rush jobs, or technical developments).
____________________
Director
________
Date
____________________
Employee
________
Date