Job Summary

Under general direction, abstract and code medical records according to International Classification of Diseases and Current Procedural Terminology coding classifications; perform related duties as required.

Distinguishing Characteristics

Positions in this class are characterized by primary responsibility to abstract and code the most complex patient charts such as for hospital inpatient and/or the hospital portion of outpatient surgery medical records.

Duties may include, but are not limited to, the following:

1. Review charts and identify procedures; abstract and code patient charts utilizing International Coding of Diseases (ICD) and Current Procedural Terminology (CPT) coding classifications.

2. Evaluate charts for completeness and accuracy in conformance with current standards and regulations; contact hospital staff to complete charts and/or to clarify information for coding purposes.

3. Participate in performance improvement projects; assist with special studies and research projects as requested by medical staff.

Pay Range: $25.50 - 29.64

Medical Records Coder II must possess and maintain current certification as Clinical Coding Specialist (CCS), Registered Health Information Technician (RHIT) or Registered Health Information Administrator (RHIA) from the American Health Information Management Association (AHIMA); or possess and maintain current certification as a Certified Professional Coder (CPC) from the American Academy of Professional Coders (AAPC).

Minimum Requirements

Credentials: Must possess and maintain one of the following:

• Registered Health Information Administrator (RHIA) issued by the American Health Information Management Association (AHIMA).

• Registered Health Information Technician (RHIT) issued by the American Health Information Management Association (AHIMA).

• Certified Coding Specialist (CCS) issued by the American Health Information Management Association (AHIMA).

• Certified Professional Coder (CPC) issued by the American Health Information Management Association (AHIMA).

AND

Experience: One of the following options:

Option 1) Two (2) years of experience (within the past five (5) years) coding inpatient stays in a Level I or II Trauma Center utilizing ICD-9 or 10 (International Coding of Diseases) and CPT (Current Procedural Terminology) coding classifications. Indicate the level on supplemental questionnaire.
Option 2) Three (3) years of experience (within the past five (5) years) coding inpatient stays in an acute care hospital utilizing ICD-9 or 10 (International Coding of Diseases) and CPT (Current Procedural Terminology) coding classifications.

Note: Medical billing is not considered qualifying experience (i.e., experience billing for supplies and services related to routine patient visits such as charge codes or coding from encounter forms).