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Primary Medical Coder

Summary/Objective

Perform intake and coding validation on medical records and enter the corresponding data into Clinical Data Abstraction Tool (CDAT) in accordance with contractual and organizational guidelines. Assist Project Director with any additional responsibilities requested.

Essential Functions

  1. Perform primary coding validation review of inpatient, outpatient, and physician office medical records per Risk Adjustment Data Validation (RADV) guidelines.
  2. Perform intake Submission Review quality checks on each medical record submitted to ensure the submitted medical record documentation is in the required order, the pages of each submitted medical record file are properly oriented, the information on the Medical Record Coversheet is correctly displayed in CDAT. Record all process information in CDAT in accordance with contract and organizational guidelines and processes.
  3. Review feedback from Senior Coders to improve accuracy and quality of work.
  4. Accurately enter data into encoder, CDAT, and other as required software using a personal computer, keyboard and/or mouse.
  5. Follow all established processes and procedures.
  6. Report problems to Project Director with regard to unique record or process issues.
  7. Maintain security and confidentiality of medical records and Protected Health Information (PHI).
  8. Consistently meet or exceed productivity and accuracy standards established by the customer and/or the company
  9. Consistently meet attendance standards established by the company.
  10. Interact appropriately with peers, co-workers, other Contractors, and the customer, when necessary. Contribute to building a positive team spirit.
  11. Perform other duties and projects as assigned.

Required Education and Experience

A minimum of one (1) year of experience in coding general acute hospital (inpatient and outpatient ) and/or multi-specialty physician office medical records by applying ICD-9-CM/ICD-10-CM coding guidelines. RHIA, RHIT or CCS certification required.

 

Skills & Abilities

  • Ability to work independently and maintain an elevated level of concentration.
  • Capable of consistency, speed, and accuracy of task.
  • Ability to read, analyze, and interpret physician documentation.
  • Ability to communicate clearly and professionally with all levels of the organization, both written and verbal
  • Ability to work well in a team environment, to collaborate with others, and interface with team members internal and external to the organization
  • Establishes and maintains effective professional relationships with internal and external stakeholders
  • Must be able to adapt to organizational change
  • Must be proficient in Microsoft Office Suite
  • Flexibility and ability to plan, prioritize, and execute multiple tasks in a fast paced environment
  • Self-motivated, well-organized, and detail oriented
  • Ability to maintain a high level of confidentiality and integrity
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