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Medical Records Technician (Coder)

The Medical Record Technician (Coder) is assigned to Medical Administration Service, Health Information Management Section at Illiana Health Care System.
The incumbent functions as the Outpatient/Inpatient Coder at this highly-affiliated multi-care facility and is responsible for the overall operations of outpatient coding, inpatient coding, surgery coding, and coding for professional fee charges.
This position is responsible for maintaining the quality of patient records, assigning of appropriate International Classification of Diseases Clinical Modification (ICD), Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes.
Duties include but are not limited to the following:
o Researches and codes all assigned work based on established or stated priorities.
o Codes diagnosis, operations and procedures based on knowledge of coding systems, including ICD, CPT, and HCPCS, ensuring that codes are complete and conform to accepted VA regulations, ICD coding conventions, Centers for Medicare and Medicaid Services (CMS) guidelines, and VHA guidelines.
o Reviews patients' records to ensure that all conditions of care, operations and procedures are properly documented by the clinician.
o Completes inpatient and pro-fee coding on all inpatient charts within established time frames.
o Codes assigned outpatient encounters within established time frames.
o Must be able to work independently.
o Manages time, specifically schedules, prioritizes deadlines, and requests, and maintains productivity standards.
o Communicates appropriately both verbally and in writing with professional, administrative, and technical personnel.
o Performs other related duties as assigned.
Work Schedule:
Monday-Friday (7:
30a-4:
00p)Functional Statement Title/#:
Medical Records Technician

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