CODER/HEALTH INFORMATION MANAGEMENT TECHNICIAN/Full-time

Boundary Community Hospital; United States; On-site; USD 55,000 - 75,000; Full time

Job summary

Boundary Community Hospital is seeking a HIM Coder/Technician II to ensure patient records meet regulatory standards and coding supports proper reimbursement. The role includes chart review, transcription, ROI, and data maintenance across departments.

The position requires CCS certification (or equivalent), strong Medical Terminology, excellent interpersonal and communication skills, and proficiency with EMR systems such as Meditech or EPIC. Full-time M-F, 7am-3:30pm, on-site.

Qualifications

• High School Diploma required.
• CCS coding certification from AAPC or AHIMA (or accredited college) is required/strongly preferred.
• RHIT certification preferred.
• Experience with ICD diagnostic, CPT procedural, and HCPCS coding in hospital or clinic settings.
• Advanced knowledge of Medical Terminology and strong interpersonal/communication skills.

Responsibilities

• Code ED, Outpatient, and Inpatient accounts following coding guidelines for reimbursement.
• Complete chart reviews for accuracy and completeness.
• Contact physicians/ancillary staff to obtain correct diagnoses for coding.
• Transcribe STAT dictations as priority and other transcription as needed.
• Process requests for copies of medical records and respond to information requests.

Skills

Interpersonal skills

Communication skills

Medical Terminology knowledge

Data analysis

Documentation accuracy

Education

High School Diploma

CCS coding certification (AAPC/AHIMA)

RHIT certification (preferred)

Tools

Alpha II coder

Code Correct

AMA ICD-10-CM

HCPCS coding books

Meditech

EPIC

Job description

POSITION SUMMARY:

The HIM Coder/Technician II is responsible for ensuring patient record documentation meets state and federal regulations and physician documentation supports coding. This position will apply all official coding guidelines when assigning diagnostic and procedure codes for both inpatient and outpatient accounts based on health record documentation. This position will assist the HIM Manager with daily activities of the department, including release of information (ROI), scanning and validating paper documents, compiling statistics, gathering data for trauma and cancer registries, filing, transcribing, and maintenance of data dictionaries.

SCHEDULE: Full-time; M-F, 7am-3:30pm

SSENTIAL JOB DUTIES/REQUIREMENTS:

• Ensure patient record documentation meets state and federal regulations for content, completeness, and timeliness.
• Code ED, Outpatient, and Inpatient accounts correctly to ensure coding guideline are followed for appropriate reimbursement, utilizing Alpha II coder, Code Correct, and AMA ICD-10-CM, and HCPCS coding books.
• Accurately completes chart review to ensure accuracy and completeness for analytical, statistical, and patient care purposes.
• Call physicians and ancillary departments to get correct diagnosis to complete coding procedures.
• Physically locate and wait for physicians, nursing staff, and therapists to obtain correct diagnosis to complete coding procedures.
• Assures timely completion of chart deficiencies by promptly recording such deficiencies in the ICR desktop and by providing healthcare staff with the information they require to complete the deficiencies.
• Receiving calls from ancillary departments, physician offices, etc to get correct ICD-10 and CPT coding.
• Transcribes STAT dictations as a priority and other transcription as needed.
• Refer inconsistent or incorrect coding by provider to management when a trend or pattern is identified.
• Respond and process all requests for copies of medical records from other healthcare facilities, over the phone, and walk-in requests, ensuring correct requests are filled out properly.
• Responsible for establishing and maintaining healthy interpersonal relationships with all staff members.
• Recognize the important part this position plays in Performance Improvement of the ongoing delivery of patient care.
• Reacts properly and follows correct policy and procedure in an emergency and/or disaster.
• Must wear Personal Protective Equipment (PPE) as situations require maintaining Infection Control standards set by hospital.

Qualifications

POSITION QUALIFICATIONS:

• High School Diploma required plus CCS coding certification from AAPC or AHIMA, or accredited college, or a minimum of 5 years of applicable ICD diagnostic, CPT procedural, and HCPCS coding in a hospital or diverse specialty physicians office.
• RHIT certification preferred.
• Experience interpreting a variety of instructions in written, oral, diagram, or schedule form.
• Must have advanced knowledge of Medical Terminology and excellent interpersonal skills and communication skills both written and oral.
• Previous experience capturing data and analyzing quality measures, case mix index, and health record documentation compliance.
• Skilled in data analysis, research, and error-correction
• Strong organizational and teamwork skills.
• Ability to effectively present information and respond to questions concerning statistics, coding, and transcription.
• Advanced computer skills in Microsoft programs, Word, Excel, Outlook and Electronic Medical Records (EMR), Meditech or EPIC preferred. Must keyboard at 50 wpm.