Coder Medical Records Resume Samples
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Coder Medical Records Resume Samples
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ER
E Rempel
Era
Rempel
498 Henri Meadow
Boston
MA
+1 (555) 726 8536
498 Henri Meadow
Boston
MA
Phone
p
+1 (555) 726 8536
Experience
Experience
Phoenix, AZ
Practice Medical Records Coder
Phoenix, AZ
Monahan-Waelchi
Phoenix, AZ
Practice Medical Records Coder
- Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment
- Applies the Uniform Hospital Discharge Data Set definitions as well as any additional regulatory guidelines and/ or coding references (Coding Clinic, 3M references) to select the principal diagnosis, secondary diagnoses, and all significant procedures as documented in the medical record
- Reports diagnoses and their associated Present on Admission Indicator (POA) and procedures in accordance with the established International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) Official Guidelines for Coding and Reporting
- For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets
- Applies and adheres to Outpatient Perspective Payment System (OPPS), APC foundations and the use of Correct Coding Initiatives (CCI) edits during CPT procedure selection
- Analyzes medical records for completeness of documentation and contacts physicians for clarification for any incomplete/ambiguous or conflicting documentation
- Serves as an onsite resource for CPT-4 and ICD-10-CM coding concerns
Dallas, TX
Senior Medical Records Coder
Dallas, TX
Renner, Fahey and Cartwright
Dallas, TX
Senior Medical Records Coder
- Perform prospective and retrospective internal audits
- Performs in depth analysis of medical records to abstract diagnoses and procedures
- As necessary, provides Physicians and other staff with information relative to coding
- Insures integrity of data prior to transmission
- Inputs data into computer for billing, research, and clinical analysis purposes
- Follow-Up:Responsible for communication with outside coding company pertaining to follow up, reconciliation and problem resolution to ensure accuracy and timely coding of all patient charts.Monitor spreadsheets to ensure discrepancies are resolved and communicated in a timely manner
- Inputs data into computer for billing, research and clinical analysis purposes
present
San Francisco, CA
Medical Records Senior Coder
San Francisco, CA
Boehm-Huel
present
San Francisco, CA
Medical Records Senior Coder
present
- Perform as a team member with other coders and providers to improve and maintain coding processes
- Work independently in Provider location or from Home depending on office
- Performs accurate and timely review and validation of Medicare Advantage - Hierarchical Condition Categories (HCCs) through medical record reviews
- Monitor accuracy of physician documentation and coding for compliance
- Responsible for communication to physicians and medical staff on the importance of medical record documentation and coding accuracy
- Some type of coding certification, which may include Certified Professional Coder (CPC), Certified Coding Specialist for Providers (CCS-P), Certified Coding Specialist for Hospitals (CCS-H), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA), or nursing medical background
- Responsible for review of Medical Records. Identify coding and documentation deficiencies
Education
Education
Bachelor’s Degree in Health Information Technology
Bachelor’s Degree in Health Information Technology
University of Southern California
Bachelor’s Degree in Health Information Technology
Skills
Skills
- Ability to communicate with clinical staff for specific coding and documentation issues such as
- Knowledge of Medical Terminology
- Skills to Code Medical Records
- Customer Service
- Technical Competence
- Skills in Training and Internal Audits
- Self-Management
- Decision Making
- Learning
- Planning and Evaluating
4 Coder Medical Records resume templates
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1
Home Care Medical Records Coder Resume Examples & Samples
- Review the complex (problematic coding that needs research and reference checking) medical records and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and/or CPT coding conventions
- Review medical record documentation and accurately code the primary/secondary diagnoses and procedures using ICD-10-CM and CPT-4 coding conventions. Sequence the diagnoses and procedures using coding guidelines. Ensure DRG/APC assignment is accurate. Abstract and compile data from medical records for appropriate optimal reimbursement for hospital and/or professional charges
- Consult with and educate physicians on coding practices and conventions in order to provide detailed coding information. Communicate with nursing and ancillary services personnel for needed documentation for accurate coding
- Maintain a thorough understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques through participation in continuing education programs to effectively apply ICD- 10-CM and CPT-4 coding guidelines to inpatient and outpatient diagnoses and procedures
- Maintain a thorough understanding of medical record practices, standards, regulations, The Joint Commission, Health Care/Finance Administration (HCFA), Medical Review of North Carolina (MRNC), etc
- RHIA certification- no experience required
- RHIT certification- no experience required
- CCS certification- one year of coding experience required
- Coding software familiarity
2
Senior Medical Records Coder Resume Examples & Samples
- Insures integrity of data prior to transmission
- Inputs data into computer for billing, research, and clinical analysis purposes
- Reports reportable diagnoses to New York State Congenital Malformation and Alzheimer Registries
- As necessary, provides Physicians and other staff with information relative to coding and DRG's
3
Observation Medical Records Coder Resume Examples & Samples
- Statistical Reporting
- Medical Terminology
- ICD-9-CM & CPT-4 coding conventions
- Anatomy and Physiology
- Reimbursement Methodologies
- Extensive DRG/APC/CCI/LCD/NCD reimbursement knowledge
4
Medical Records Technician Coder Resume Examples & Samples
- Resume: A resume describing your job-related qualification is required and must be in English. It should contain each position title, grade (if Federal), your duties, accomplishments, the dates you held each position in mm/yy format, and your work schedule and salary so we may best assess your qualifications. If more than one resume is received, only the last resume received and processed will be reviewed
- VA Form 10-2850c - Application for Associated Health Occupations (required). Available at the VA Forms website: http://www.va.gov/vaforms/search_action.asp?FormNo=10-2850&tkey=&Action=Search
- SF-50, Notification of Personnel Action. Your most recent SF-50 (non-award) must be submitted which reflects your grade, step salary, and tenure
- Transcript (only required if you are using education to qualify): A copy of your transcript showing degree and confer date. Failure to provide transcripts will result in you being rate ineligible for this position. We accept unofficial transcripts, as long as they contain the applicant's name, name of the school, the date and degree that was awarded. If you are using foreign education to meet qualification requirements, you must send a "Certificate of Foreign Equivalency" with your transcript in order to receive credit for that education
5
Supervisory Medical Records Technician Coder Resume Examples & Samples
- (a) Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses
- (b) Successful completion of a course for medical technicians, hospital corpsmen, medical service specialists, or hospital training obtained in a training program given by the Armed Forces or the U.S. Maritime Service under close medical and professional supervision may be substituted on a month-for-month basis for up to six months of experience provided the training program included courses in anatomy, physiology, and medical record techniques and procedures. Also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record
- AND*
- Ability to perform a full range of supervisory duties, to include assigning, planning and evaluating work, recommending awards, approving leave and resolving staff issues
- Ability to provide or coordinate staff development and training
- Ability to coordinate work in order to complete duties in an accurate and timely fashion
- Leadership and managerial skills including skill in interpersonal relations and conflict resolution to deal with employees, team leaders, and managers
- To begin, click to create a USAJOBS account or log in to your existing account. Follow the prompts to select your USAJOBS résumé and/or other supporting documents and complete the occupational questionnaire
- Résumé or application link: http://www.va.gov/vaforms/medical/pdf/vha-10-2850c-fill.pdf
- Online Questionnaire. View Occupational Questionnaire
- If you are a current or formal Federal Employee, you must include your latest SF-50, Notification of Personnel Action which shows your position title/grade and step (do not submit an Award SF-50). Also provide the SF-50 that reflects the highest grade level held on a permanent basis or the full performance level of your current position, whichever is higher. Failure to do so will result in an ineligible rating
- If you are using education to meet experience requirement, you must submit proof of education. Unofficial transcript may be submitted with application. If selected, you will be required to submit an official transcript
6
Medical Records Technician Coder Clinical Documentation Improvement Specialist Resume Examples & Samples
- Ability to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the heath record
- Knowledge of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines
- Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues
- Complete and current professional resume or CV
- VA Form 10-2850c - Application for Associated Health Occupations. Available at the VA Forms website: http://www.va.gov/vaforms/search_action.asp?FormNo=10-2850&tkey=&Action=Search
- Responses to the Occupational Questionnaire. (Listed within the Application Manager program when you click on the "" button)
- Please use the checklist to ensure you have included other documents required for your application, such as a copy of your transcript (if using education to qualify), documentation to support Veterans Preference claims, etc. You will not be contacted for additional information
7
Senior Medical Records Coder Resume Examples & Samples
- Performs in depth analysis of medical records to abstract diagnoses and procedures
- Confers with Physicians to obtain greater specificity and/or clarification on possible diagnoses
- Uses thorough knowledge of coding systems and edit logic to assign appropriate codes. Understands third party payers to enable selection of appropriate codes and sequencing, including modifier assignment
8
Medical Records Technician Coder Citizens Resume Examples & Samples
- Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures, etc. to ensure proper code selection
- Adheres to accepted coding practices, guidelines and conventions when choosing appropriate diagnosis, operation, procedure, etc
- Performs comprehensive reviews of patient records to abstract medical, surgical, ancillary, demographic, social and administrative data to ensure complete data capture
- Utilizes the facility computer system and software applications to enter coding as well as other day to day activities
- Orients and instructs new personnel and/or students from affiliated programs on unit operations, coding, abstracting and use of an electronic medical record
- Works within a team environment, supports peers, handles multiple tasks and copes with frequently changing projects and deadlines
- Ability to utilize health information technology and various office software products utilized in MRT coder positions (e.g., the electronic health record, coding and abstracting software, etc.)
- Knowledge of the Joint Commission requirements, Centers for Medicare & Medicaid Services (CMS), and/or health record documentation guidelines; and
- Ability to apply laws and regulations on the confidentiality of health information (e.g., Privacy Act, Freedom of Information Act, and Health Insurance Portability and Accountability Act (HIPAA)); and
- Skill in reviewing and correcting system or processing errors and ensuring all assigned work is complete
- Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding, and to evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient
- Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees; and
9
Medical Records Technician Coder Resume Examples & Samples
- Click ‘' to create an account or log in to your existing USAJOBS account
- Follow the prompts to complete the assessment questionnaire and upload required documents
- Please ensure you click the Submit My Answers button to submit your application
- Applications must be received by the closing date of the announcement to receive consideration
- Check application status by logging into your USAJOBS account, clicking Application Status, then More Information for this position. Return to an incomplete application by clicking in the vacancy announcement and re-selecting your resume and/or other documents from your USAJOBS account
- Click to view and print the assessment questionnaire View Occupational Questionnaire
- Print this 1203FX form to provide your response to the assessment questionnaire http://www.opm.gov./Forms/pdf_fill/OPM1203fx.pdf
- You are limited to selecting 10 locations
- Fax the completed 1203FX form along with any supporting documents to 1-478-757-3144. Your 1203FX will serve as a cover page for your fax transmission
- Medical Records Technician
- Technical Competence
- Self-Management
- Veterans , i.e. (VEOA, VRA, and 30% or more disabled) - https://www.opm.gov/policy-data-oversight/veterans-services/vet-guide/
- Career Transition Assistance Program (CTAP) - http://www.ihs.gov/jobs/permanentDocs/ctap.doc
- Interagency Transition Assistance Program (ICTAP) - https://www.opm.gov/policy-data-oversight/workforce-restructuring/employee-guide-to-career-transition/
- Schedule A Appointments for the Disabled - https://www.opm.gov/policy-data-oversight/disability-employment/hiring/
- Resume: You You are highly encouraged to use USAJOBS Resume Builder to ensure all required information is included in your Resume. If you use your own resume, curriculum vitae, or any other written form you choose then you must describe your job-related qualifications that includes beginning and ending dates for paid and non-paid work experience (month and year), hours worked per week, annual salary, and description of job duties. Include name and address of employer; supervisor name and telephone number
- Indian Preference Applicants: Indian preference will not be given unless a properly signed and dated Form BIA-4432 (Verification of Indian Preference for Employment in the BIA and IHS Only) is submitted with your application, including any verification by an authorized Tribal Representative or BIA Official of tribal enrollment records, this may include the completion of the family history chart if necessary. If you are obtaining a new form you must provide a completed copy of the Form BIA-4432 with expiration date 1/31/2018. For detailed instructions on how to obtain a completed form, see Form BIA-4432. You must also complete the family history chart if necessary. Refer to BIA-4432 link: http://www.bia.gov/cs/groups/xois/documents/document/idc1-029504.pdf
- Veterans Employment Opportunity Act (VEOA) or other Veterans preference (VRA and 30% or more disabled): include a copy of your DD-214, if you're claiming Vet preference. For more information please see link at:http://opm.gov/policy-data-oversight/veterans-services/vet-guide/
- Career Transition Assistance Program (CTAP)/Interagency Career Transition Assistance Program (ICTAP) – If you are claiming CTAP/ICTAP, follow the instructions below: http://www.opm.gov/policy-data-oversight/workforce-restructuring/employee-guide-to-career-transition/ctap_guideline.pdf
- Certification: Certification as a Certified Professional Coder
10
Medical Records Technician Coder Resume Examples & Samples
- 465683500
- Veterans , i.e. (VEOA, VRA, and 30% or more disabled)
- Career Transition Assistance Program (CTAP )
- Interagency Transition Assistance Program (ICTAP)
- Schedule A Appointments for the Disabled
- Resume - You are highly encouraged to use USAJOBS Resume Builder to ensure all required information is included in your Resume. If you use your own resume, curriculum vitae, or any other written form you choose then you must describe your job-related qualifications that includes beginning and ending dates for paid and non-paid work experience, hours worked per week, month and year of employment for each job title listed, annual salary, and description of job duties. Include name and address of employer; supervisor name and telephone number
- Indian Preference Applicants - If claiming Indian preference, applicants must provide a completed copy of the Form BIA-4432, "Verification of Indian Preference for Employment in the BIA and IHS Only." Indian preference will not be given unless a properly signed and dated form is submitted with your application, including any verification by an authorized Tribal Representative or BIA Official of tribal enrollment records. For detailed instructions, see form BIA-4432. Refer to BIA-4432 link: http://www.bia.gov/cs/groups/xois/documents/document/idc1-029504.pdf. When an Indian Preference candidate possesses Veteran's preference the rules regarding Veterans' preference apply under ESEP and the applicant must provide documentation in order to receive preference
- Veteran's Preference – If claiming Veteran's Preference provide a copy of your DD214 Form (Member 4 copy). To claim 10-Point Veteran's Preference, submit a SF-15 Application (http://www.opm.gov/forms/pdf_fill/SF15.pdf) along with the appropriate supporting documentation. For additional information regarding Veteran's Preference visit: www.fedshirevets.gov
11
Medical Records Technician Coder Resume Examples & Samples
- Business travel up to 5% may be required
- Knowledge of Medical Terminology
- Skills in Training and Internal Audits
- Skills to Code Medical Records
- To return to an incomplete application, log into your USAJOBS account and click Update Application in the vacancy announcement. You must re-select your resume and/or other documents from your USAJOBS account or your application will be incomplete
- It is your responsibility to verify that information entered, uploaded, or faxed (i.e., resume) is complete, accurate, and submitted by the closing date. Uploaded documents may take up to one hour to clear the virus scan. Faxed documents must be completely transmitted (fax and scan complete) by 11:59 PM (EST) on the closing date of the announcement
12
Medical Records Technician Coder Auditor Resume Examples & Samples
- Knowledge of the applicable regulatory guidelines and requirements for current coding conventions
- Knowledge of coding classification systems
- Ability to review coded data and supporting documentation to identify adherence to applicable standards, coding conventions, and documentation requirements; and
- Ability to format and present results and provide guidance to improve accuracy
- To begin the process, click the button at the bottom of this screen to create an account or log in to your existing USAJOBS account. Follow the prompts to select your USAJOBS resume and/or other supporting documents and complete the occupational questionnaire
- Click the Submit My Answers button to submit your application package
- CV or Resume (required)
- VA Form 10-2850c - Application for Associated Health Occupations (Available at http://www.va.gov/vaforms/medical/pdf/vha-10-2850c-fill.pdf ) (required)
- Occupational Questionnaire (required)
- If prior military service, include all copies of your DD Forms 214 or proof of service (required)
- Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must also complete and submit an SF 15, Application for 10-Point Veteran Preference (available at http://www.opm.gov/forms/pdf_fill/SF15.pdf )
- SF-50 - Notification of Personnel Action (required) if a current or prior Federal employee
- OF-306, Declaration for Federal Employment ( http://www.opm.gov/forms/html/OF.asp)
13
Medical Records Senior Coder Resume Examples & Samples
- Maintain current knowledge of coding and documentation guidelines
- Performs accurate and timely review and validation of Medicare Advantage - Hierarchical Condition Categories (HCCs) through medical record reviews
- High school diploma or equivalent required with college preferred
- HCC coding experience required
- Strong knowledge of medical terminology and anatomy and physiology
- Proficiency with ICD-9-CM & ICD-10-CM coding and guidelines with 2 or more years of working knowledge required
- Strong internal and external customer service skills
- Some type of coding certification, which may include Certified Professional Coder (CPC), Certified Coding Specialist for Providers (CCS-P), Certified Coding Specialist for Hospitals (CCS-H), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA), or nursing medical background
- Must be able to operate in a production environment and meet company guidelines for productivity and quality
- Knowledgeable of Medicare Risk Adjustment
- Must be detail oriented, self-motivated, and have excellent organization skills
- Work independently in Provider location or from Home depending on office
14
Practice Medical Records Coder Resume Examples & Samples
- Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment
- Applies the Uniform Hospital Discharge Data Set definitions as well as any additional regulatory guidelines and/ or coding references (Coding Clinic, 3M references) to select the principal diagnosis, secondary diagnoses, and all significant procedures as documented in the medical record
- Reports diagnoses and their associated Present on Admission Indicator (POA) and procedures in accordance with the established International Classification of Diseases 9th Revision Clinical Modification (ICD-9-CM) Official Guidelines for Coding and Reporting
- Assigns and reports all other data elements required for (Statewide Planning and Research Cooperative System) SPARCS data collection
- Applies and adheres to Outpatient Perspective Payment System (OPPS), APC foundations and the use of Correct Coding Initiatives (CCI) edits during CPT procedure selection
- Logs all discharges into the computerized Discharge Log, enters specific data elements and assigns appropriate discharge physician
- Assist in the education of physicians and other clinicians by advocating proper documentation practices, further specificity, and re-sequencing and inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity and occurrence of events
- Serves as an onsite resource for CPT-4 and ICD-10-CM coding concerns
- Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines, and regulations
- Demonstrates the correct use of the automated medical record tracking system
- High School Diploma or equivalent, required
- In Patient Coding: Certified Coding Specialist (CCS) credentials, required
- Out Patient Coding: Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician, required
- Minimum of two (2) years prior coding experience in an acute care setting, required
- Thorough knowledge of ICD-10-CM, CPT-4, HCPCS, and DRG coding and classification systems, required
15
Supervisory Medical Records Technician Coder Resume Examples & Samples
- Ability to accurately perform the full scope of outpatient coding, including ambulatory surgical cases, diagnostic studies and procedures, and outpatient encounters, and/or inpatient coding, including inpatient discharges, surgical cases, diagnostic studies and procedures, and inpatient professional fees
- Skill in interpreting and adapting health information guidelines and ability to use judgment in completing assignments using incomplete or inadequate guidelines
- VA Form 10-2850c - Application for Associated Health Occupations (Available at http://www.va.gov/vaforms/medical/pdf/vha-10-2850c-fill.pdf) (Required)
- OF306 -Declaration for Employment - This document is preferred, but not required at this phase of the application process. Please note, this form has been recently updated and is available at this link: http://www.opm.gov/Forms/pdf_fill/OF306.pdf
- Responses to the questionnaire. (Required)
- If prior military service, include all copies of your DD Forms 214 or proof of service (required). Applicants claiming preference based on service-connected disability, or based on being the spouse or mother of a disabled or deceased Veteran, must also complete and submit an SF 15, Application for 10-Point Veteran Preference (available at http://www.opm.gov/forms/pdf_fill/SF15.pdf)
- Most Recent SF-50 - Current or former Federal employees must provide a copy of their most recent SF-50 "Notification of Personnel Action" that indicates time in grade, proof of status (career or career conditional) and type of service. (Not an Award SF-50)
- If you are a virtual employee physically located at the James H. Quillen VA Medical Center (JHQVAMC) and you wish to be considered in the first area of consideration along with other facility employees, you must ALSO provide evidence of your eligibility such as a signed memorandum, commitment letter, etc. indicating that such an agreement is in place. (Required if applicable)
16
Medical Records Technician Coder Clinical Documentation Improvement Specialist Cdis Resume Examples & Samples
- 1) Six months of experience that indicates knowledge of medical terminology and general understanding of the health record and one year above high school with a minimum of 6 semester hours of health information technology courses
- 2) Successful completion of a course for Medical Technicians, Hospital Corpsmen, Medical Service Specialist, or hospital training obtained in a training program given by the Armed Forces or the US Maritime Service under close medical and professional supervision? (This experience may be substituted on a month-for-month basis for up to six months provided the training program included courses in anatomy, physiology, and medical record techniques and procedures. This also requires six additional months of experience that indicates knowledge of medical terminology and general understanding of the health record.)
- One year of experience comparable to the next lower grade level (GS-8)
- To be creditable, the candidate's experience must have demonstrated the use of knowledge, skills, and abilities associated with current health information or health record technology and/or cancer registry practice and may be paid or non-paid employment
- Knowledge of anatomy and physiology, pathophysiology, and pharmacology
- Ability to establish and maintain strong verbal and written communication with providers
- Knowledge of regulations that define healthcare documentation requirements
- Knowledge of training methods and teaching skills sufficient to conduct continuing education for staff development
- SF50 (Current and prior Federal employees)
- VA Form 10-2850C: Application for Associated Health Occupations. This form is available at the following website: http://www.va.gov/vaforms/search_action.asp?FormNo=10-2850&tkey=&Action=Search
- OF-306
- Other Veterans Document
- Transcripts
17
Medical Records Technician Coder Resume Examples & Samples
- Skill in interpreting and adapting health information guidelines
- Resume/Application
- Completed online questionnaire
- Transcripts (If using Education to qualify)
- Copies of Certifications (if applicable)
18
Senior Medical Records Coder Resume Examples & Samples
- Inputs data into computer for billing, research and clinical analysis purposes
- Prepares report as requested and related clerical tasks
- Attends meetings relating to coding and billing along with attending seminars and review payer and coding websites to maintain the most current coding and practice changes as well as specific third-party coding requirements for hospital based and faculty practice billing
- Perform prospective and retrospective internal audits
19
Practice Medical Records Coder Westchester Health Medical Resume Examples & Samples
- Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/ or coding references (Coding Clinic, 3M references) to select the principal diagnosis, secondary diagnoses, and all significant procedures as documented in the medical record
- Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures in accordance with the established International Classification of Diseases 10th Revision Clinical Modification (ICD-10-CM), International Classification of Diseases 10th Revision Procedure Classification System (ICD-10-PCS) Official Guidelines for Coding and Reporting
- Reports a discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations
- Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection
- For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets
- Assigns appropriate discharge physician in the system
- Analyzes medical records for completeness of documentation and contacts physicians for clarification for any incomplete/ambiguous or conflicting documentation
- Assist in the education of physicians and other clinicians by advocating proper documentation practices, further specificity, and resequencing and inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity and occurrence of events
- Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines and regulations
- Maintains the minimum data standards for accuracy and productivity as defined by the facility
- Associate Degree or related field, required. Bachelors preferred OR Successful completion of a medical coding course sponsored by the health system, required
- Minimum of one (1) year experience as an ICD-10 medical records coder, preferred
- Familiarity with an automated medical record tracking systems
20
Medical Records Technician Coder Resume Examples & Samples
- Ability to navigate through health records to find needed information
- Skill in interpreting and adapting health information guidelines that are not completely applicable
- Skill in reviewing and correcting system or processing errors and ensuring all assigned work is
- Ability to analyze the medical record to identify all pertinent diagnoses and procedures for coding,
- Your Résumé
- A complete Occupational Questionnaire View Occupational Questionnaire
- Additional Required Documents (see Required Documents section below)
- Résumé or Optional Application for Federal Employment (OF-612)
- Responses to the questionnaire
- Copy of your transcript if you are using education to qualify
- Evidence of your eligibility to apply for this vacancy (please see checklist)
- Any other documents required by the checklist
21
Medical Records Senior Coder Resume Examples & Samples
- Responsible for communication to physicians and medical staff on the importance of medical record documentation and coding accuracy
- Looks for opportunities for process improvement and reports that information to appropriate person
- Strong knowledge in medical terminology, anatomy and physiology, ICD-9/ICD-10 and CPT-4 coding with 1 or more years of working knowledge required
- CPC (Certified Professional Coder) or any other coding certification through AAPC or AHIMA
- Experience with HCC coding strongly preferred