Responsible for coding all medical records according to diseases, operations, procedures, and other factors influencing health status and contract with health services. Interprets context, intent of medical terminology and data in the record in order to accurately code all diagnoses and operations for classification and retrieval purposes. Inputs data into the 3M Code 3 computerized DRG/APC Groupers and Code finder to derive most adequate codes numbers for optimum reimbursement. Follow Department Policy and Official Coding Guidelines. Analyzes and abstracts medical records for statistical information such as discharge service and physicians credited with participation, discharge disposition, newborn birth weight and other data as required.
Registered Health Information Management Administrator (RHIA) or Technician (RHIT) graduate of an approved college program for Health Information Management or graduate of the American Medical Record Association's Independent Study Course for Medical Record Technicians; or Certified Coding Specialist (CCS).
If not certified must be eligible to take one of the above mentioned exams, and must obtain credentials/certifications within 12 months of hiring date.
College courses in medical terminology and anatomy and physiology.
Demonstrate competence by achieving an accuracy ratio of greater than 96% on hospital coding examination.
Three (3) years previous acute hospital inpatient and outpatient coding experience required.
Must possess a good background in medical terminology and anatomy and physiology as the fundamentals of medical science.
Must be knowledgeable of the application of the International Classification of Diseases and Operations, Ninth Revision, Clinical Modification, (ICD-9-CM), and Current Procedural Terminology (CPT), Diagnosis Related Groups (DRG) and Ambulatory Payment Classifications (APC).
Must be familiar with physicians' handwriting.
Must be familiar with the content and arrangement of the medical record.
Must be familiar with other functions in Medical Records and how they relate to the Coding function.
Registered Health Information Management Technician (RHIT).
Registered Health Information Management Administrator (RHIA).
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.