Medical Records Coding Technician abstracts clinical information from medical records and assigns the appropriate ICD or CPT codes using industry-standard coding guidelines. Assigns required DRG (diagnosis-related grouping) codes. Being a Medical Records Coding Technician works with coding databases and software to input and maintain data according to standard procedures. Performs quality audits of work. Additionally, Medical Records Coding Technician maintains and up-to-date knowledge of coding and documentation requirements. Requires a medical coding certification. The exact type of coding certification may vary based on the clinical setting or a medical specialty focus. May require an associate degree. The AAPC Certified Professional Coder (CPC) certification is typically required. The Certified Coding Specialist (CCS) certification is also a typical requirement. Typically reports to a supervisor or manager. The Medical Records Coding Technician works independently within established procedures associated with the specific job function. Has gained proficiency in multiple competencies relevant to the job. To be a Medical Records Coding Technician typically requires 3-5 years of related experience. (Copyright 2024 Salary.com)
Reporting to the Director of Health Information Management, this
position is responsible for facilitating concurrent documentation of the
medical record to achieve accurate inpatient coding and legitimate DRG
assignment. Provide clinically based concurrent and retrospective review of
inpatient medical records to evaluate the utilization and documentation of
acute care services. Includes facilitation of appropriate physician documentation
of care to accurately reflect patient severity of illness and risk of
mortality. This position plays a significant role in reporting quality of care
outcomes and in obtaining accurate and compliant reimbursement for acute care
services. 2.
CCDS or CDIS certification preferred upon hire or transfer.
Successful completion of CCDS or CDIP certificate
examination within three years and nine months from date of hire. 3. CDS
I requires current
valid California LVN license.
QUALIFICATIONS:
1. 3-5 years clinical experience in an acute care setting preferred. Case
Management and/or coding experience a plus.
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