Coder II

J  o  b    D  e  s  c  r  i  p  t  i  o  n

          Joy                         Care                      Competence                    Respect

Position Summary

The Coder II codes healthcare records for the purpose of accurate data, reimbursement, research, statistics for planning and comparative quality data in compliance with federal regulations according to diagnosis, operation(s) and procedure(s) using the latest edition of International Classification of Diseases (ICD) classification system, Current Procedural Terminology (CPT) system and Evaluation and Management (E&M) guidelines. Assigns charges including but not limited to emergency department and injection/infusion and abstracts as needed.

High School Diploma or equivalent is required.

Associate’s degree in business, healthcare or a related field is preferred.

2 or more years of medical coding experience is required.

Experience with electronic health/medical records (EHR/EMR) and coding software is required.

One of the certifications listed below is required:

RHIA, RHIT, CCS, CCS-P, HCS-D, or HCS-H.

COC, CIC, or CPC credentials may also be considered.

Understands Medicare regulations that relate to coding and/or DRG validation and/or APC guidelines.

Meets quality standards related to correctly coded principle diagnosis and procedures.

Maintains knowledge of all federal and state regulations and affiliate policies pertaining to coding procedures.

Utilizes computer systems effectively and efficiently.

Consistently meets productivity standards.

Proficient in coding at least two patient types or specialties.

Detail-oriented and dependable. Displays high degree of initiative. Possesses good time management skills. Demonstrates good communication skills.  Friendly and service oriented. Maintains the confidentiality of all patient information.

Identifies, codes, and/or changes records for the purpose of reimbursement, research, and compliance with federal regulations according to diagnosis, operations, and procedures using the latest edition of the ICD classification system, CPT procedure system and E&M guidelines.

Explains codes, terminology, and coding guidelines to physicians as staff.

Communicates with the business office on coding and/or billing concerns.

Collaborates with clinical documentation specialists to improve documentation and queries as needed.

Enters charges as assigned.

Serves as a mentor to Coder I colleague(s).

Participates in team meetings, and other educational opportunities

Possess the information, skill, and understanding of the work to be performed.  Actively participates in continuing education opportunities and maintains certifications, licensure as appropriate.

Abides by all safety requirements including demonstrating proper hand hygiene and wearing of Personal Protective Equipment (PPE), if applicable. 

Complies with all standards, policies and procedures including dress code, attendance and punctuality.  Attends required in-services and meetings and completes all mandatory competencies by deadline. Commits to keeping all patient, student or colleague information confidential and maintains ongoing communication and collaboration with team members. 

The purpose of this job description is to provide a summary of the major responsibilities performed by colleagues in this position. Colleagues may be requested to perform tasks other than those specifically presented in this job description.  Variances in job duties performed may exist between facilities, and colleagues may perform other related duties as assigned to meet the needs of the organization.

PHYSICAL, MENTAL AND ENVIRONMENTAL REQUIREMENTS

Physical, Mental and Environmental Requirements Category:

Administrative

Standing

X

Walking

X

Sitting

X

Lifting

X

20 lbs.

Carrying

X

20 lbs.

Pushing

X

20 lbs.

Pulling

X

20 lbs.

Climbing

X

Balancing

X

Stooping

X

Kneeling

X

Crouching

X

Crawling

X

Reaching

X

Use of Hands/Dexterity

X

Talking

X

Hearing

X

Eye/Hand/Foot Coordination

X

Extreme Cold

X

Extreme Heat

X

Humid

X

Wet

X

Noise

X

Hazards

X

Temperature Change

X

Atmospheric Conditions

X

Vibration

X

Other