Coder - Inpatient (Medical Records)

Midland Health; Midland (TX); Remote; USD 40,000 - 80,000; Full time

Job summary

An established industry player is seeking a dedicated Coder/Abstractor to work remotely. In this vital role, you will be responsible for coding hospital medical records using ICD-10-CM/PCS and CPT systems to ensure accurate billing and data retrieval. You will also abstract relevant clinical and demographic information, contributing to patient care and research. This position offers a structured schedule from Monday to Friday, allowing you to maintain a work-life balance while playing a crucial role in healthcare operations. If you are detail-oriented and passionate about healthcare coding, this opportunity is perfect for you.

Qualifications

• Understanding of coding conventions and guidelines.
• Experience in Health Information Management is preferred.

Responsibilities

• Code medical records for billing and data retrieval.
• Abstract clinical and demographic information from records.

Skills

ICD-10-CM/PCS coding

CPT coding

Clerical knowledge

Problem-solving skills

Education

High school diploma or equivalent

CCS or RHIT Certification

Previous experience in Health Information Management

Tools

Abstracting system

Computer keyboarding

Job description

Job Description

*This position is remote*

Performs the essential duties and responsibilities and the primary function of Coder/Abstractor. Identifies and codes hospital medical records for the purpose of continuing patient care, reimbursement, and research in accordance with coding and reimbursement guidelines. Codes diagnosis(es), operations(s), and procedures(s) using the ICD-10-CM/PCS and CPT coding classification systems. Codes all Inpatient, Outpatient, Observation, Same Day Surgery, Emergency Room, and Urgent Care medical records for billing purposes and data retrieval. Abstracts relevant clinical and demographic information from the medical records using the hospital’s abstracting system and in accordance with established policies and procedures. Responsible for solving practical problems dealing with a variety of issues and interpreting a variety of instructions furnished in written or oral form. Demonstrates clerical knowledge and judgement necessary to complete the job responsibilities.

SHIFT AND SCHEDULE

Monday - Friday 8:00 AM - 5:00 PM

ESSENTIAL FUNCTIONS/PERFORMANCE EXPECTATIONS

1. Complies with the ICD-10-CM/PCS and CPT coding conventions and guidelines in the Coding Clinic and demonstrates a complete understanding of the coding convention.
2. Complies with the UHDDS definitions of principal diagnosis, secondary diagnosis, principal procedure, and secondary procedures.
3. Participates in coding meetings and education conferences in order to maintain coding accuracy.
4. Abstracts relevant clinical data and demographic information from the medical record.
5. Minimum Productivity Standard: Inpatient Charts=4 per hour; Observation/Same Day Surgery Charts=6 per hour; Outpatient/Lab/Xray/Series Charts=20 per hour; ER Charts=20 per hour.

EDUCATION AND EXPERIENCE

1. A mental development equivalent to a high school graduate, capable of solving practical problems dealing with a variety of variables.
2. Prefer six months to one year previous experience in the Health Information Management Department or related clinical setting.
3. Prefer CCS or RHIT Certification.
4. Computer keyboarding experience and clerical experience.

PHYSICAL REQUIREMENTS

To perform this job successfully, an individual must be able to perform each essential responsibility satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The individual must be able to stand, walk, sit, stoop, reach, lift, see, speak, and hear. Lifting is limited to 35 lbs. for clinical staff and to 50 lbs. for non-clinical staff. The individual must use an assisted-lift device or get another individual(s) to assist with the lift that is over these maximum limits.