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"Success doesn't come to you…you go to it."
- Marva Collins
Company: Greenville Regional Hospital, Greenville, IL
Job Title: CODER
Date Posted: 09/28/2012
Industry: Health Clerical
Summary: Job Title: Medical Record Coder
Department:Health Information Management  
Reports To: Health Information Management Manager
Analyzes, codes, abstracts, and compiles medical records of patients of health care delivery system to document patient condition and treatment by performing the following duties.
ESSENTIAL DUTIES AND RESPONSIBILITIES include, but are not limited to, the following:  Functions within all policies, procedures, rules and regulations applicable to the organization.
Abstracts and codes diagnoses, operations, and procedures from health records by using appropriate classification systems, standards, and procedures, following AHIMA coding guidelines and AHIMA code ethic's.
Prepares statistical reports required by applicable legal, accrediting, and/or licensing regulations and hospital policy.
Assigns supplemental codes and other data as necessary.
Compiles information and data from health records and computer systems for use in the evaluation of quality of care and utilization review.
Monitors completion of medical records in accordance with time standards.
Audits incomplete records and prepares reports on delinquencies.
Confers with doctors, nurses, and other health personnel to assure complete, current, and accurate medical records.
Compiles and maintains logs, reports, and statistical records, and researches records to locate health data as requested.
Assists in identification of medical records needed for research, using both manual and computer indexes.
Reviews medical records for completeness and to abstract and code clinical data such as diseases, operations, procedures and therapies.
Compiles medical care and census data for statistical reports on types of diseases treated, surgery performed, and use of hospital beds, in response to inquiries from law firms, insurance companies, and government agencies.
Maintains and utilizes variety of health record indexes and storage and retrieval systems.
Operates computer to process, store, and retrieve health information.
Assists Medical Record Administrator in special studies or research, as needed.
SUPERVISORY RESPONSIBILITIES This job has no supervisory responsibilities.
QUALIFICATIONS  To perform this job successfully, and individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.
a. Education and /or Experience
Bachelor’s or Associate's degree (A. A.) or equivalent from two-year college or technical school; or six months to one year related experience and/or training; or equivalent combination of education and experience.
b. General Skills
Ability to read and comprehend instructions.  Ability to write.  Ability to respond appropriately to inquiries or complaints.  Ability to add, subtract, multiply and divide.  Ability to apply common sense and respond to instructions,
written or oral.  Ability to define problems, collect data, establish facts, and draw valid conclusions.
c. Certificates, Licenses, Registrations
Maintains current license, certifications, continuing education and other required staff development programs required by the facility and or their departmental guidelines.
PHYSICAL DEMANDS  Able to see and hear or use prosthetics that will enable these senses to function adequately to assure that the requirements of the position can be fully met.  Be in good general health and demonstrate emotional stability. 
Able to assume awkward positions (bending, stooping, squatting and reaching) on a frequent basis.  Able to move/walk, push/pull, (patients/residents, carts, wheelchairs, stretchers, equipment, boxes, etc.) on a frequent basis.
The staff member must occasionally lift and/or move up to 50 pounds.
WORK ENVIRONMENT  While performing the duties of this job, the staff member is regularly exposed to and works inside a controlled indoors environment.  Is subject to frequent interruptions.  Is involved with patients/residents, staff members,
visitors, regulatory agency personnel, etc.  May be subject to hostile and emotionally upset patients/residents, family members, staff members, or others.  May be subject to exposure from infectious waste and disease, including, but not limited to AIDS, Hepatitis B, and TB.
INTERPERSONAL SKILLS  Communicates effectively and appropriately. Gets along and cooperates with co-workers and appropriately interacts with others. Participates and functions as an effective member of the healthcare team.
CONFIDENTIALITY/PATIENTS/RESIDENT RIGHTS  Exchanges information concerning patients/residents/customers/staff members and the organization with others only on a "need to know" basis.  Understands and implements the "Bill Of Rights"
for patients and residents ensuring considerate, respectful care and privacy of any information, personal or medical that can identify a patient and or their medical record information.
ATTENDANCE  Promptly arrives for the designated shift.  Follows all applicable policies regarding schedules, attendance and organizational requirements.
SAFETY  Understands and uses safe practices at all times.  Reports all unsafe conditions to the appropriate manager immediately.  Assures all equipment functions properly before use.  Knows and adheres to all safety and fire prevention rules and regulations. 
Knows location and use of personal protective equipment, fire plan, MSDS, Disaster Plan, and Exposure Control Plan.
UNIVERSAL ACCOUNTABILITY  Provides excellent service to all customers including (patients, residents, families, visitors, volunteers, physicians and co-workers) striving to exceed their expectations. Demonstrates courtesy, compassion and respect.
Is thoroughly committed to the mission, vision, and heritage of Greenville Regional Hospital.
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