Description :Incumbents perform the most complex coding and abstracting of a high volume of patient records in the Medical Records onsite unit .This class is distinguished from the Medical Records Coder class in that the latter does not require the minimum qualification of professional certification. Medical Records Coders may promote to the Certified Medical Records Coder class with the submission of a current valid coder certification through the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) and meet the minimum qualifications for this class with a satisfactory performance evaluation.Examples of Essential DutiesCodes medical record entries pertaining to diagnoses and procedures according to the most current edition of ICD-CM and when applicable CPT; enters into the designated computer system.Abstracts patient information such as type of surgery, type of anesthesia, length of stay, and kind of service; assists physicians in research projects.Queries physicians when assistance is needed for proper identification of codes for diagnoses or procedures; communicates with physicians, Coroner's Office, and others involved in the treatment of patients as needed.Assists in the training and provides technical assistance to Medical Records Coders, Technicians, and Specialists; assists with incoming phone calls.Recruiting GuidelinesExperience: One year of medical record coding experience in an acute care setting using ICD-CM and CPT coding. (Needs to have been within the last two years.)Knowledge of: A thorough knowledge of ICD-CM and CPT classification coding systems, and DRG assignment; the fundamentals of anatomy, physiology, and the study of diseases; standard clerical office procedures and equipment including Windows-based software use.Ability to: Utilize the ICD-CM classification system to code medical record entries either by use of coding books or encoder product; abstract pertinent information from medical records; follow oral and written instructions; operate PC with Windows software, coding software and abstract package; effectively communicate technical information to medical and administrative personnel; maintain effective working relationships with others.Other RequirementsLicense/Certificate: Possession of current valid certification as a Certified Coding Specialist (CCS) or Certified Coding Associate (CCA) or Certified Coding Specialist-Physician based (CCS-P) or Registered Health Information Administrator (RHIA) or a Registered Health Information Technician (RHIT) issued by American Health Information Management Association OR Certified Professional Coder (CPC) or Certified Professional Coder-Hospital (CPC-H) issued by the American Academy of Professional Coders.VIVA is an equal opportunity employer. All qualified applicants have an equal opportunity for placement, and all employees have an equal opportunity to develop on the job. This means that VIVA will not discriminate against any employee or qualified applicant on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or protected veteran status
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