Works under the supervision of the Coding and Reimbursement Supervisor. The primary job functions of the HIM Coder Level I are to assign correct ICD-9-CM and CPT codes to established diagnoses and procedures to outpatient (emergency room, same-day surgery, interventional radiology, observation and/or Urgent Care Center) and/or inpatient records. Must be able to audit OP and IP records for charging accuracy. Adds or deletes charges for optimal reimbursement as well as compliance following coding and governmental guidelines. The level one coder has mastered a maximum of 2 work types. Performs other duties as assigned.
GED/High School Diploma required. Successful completion of medical terminology course required. Successful completion of an anatomy and physiology course preferred or willingness to enroll within the first 90 days of employment. Successful completion of a formal coding training program preferred or must enroll within the first 90 days of employment with successful completion within 3 years.
RHIT, CCS or CCA certification preferred.
Previous coding experience preferred.
D. Interpersonal Skills
Must be able to gather and exchange information with physicians, nurses, and other hospital personnel as well as outside agencies (CMS).
E. Essential Technical/Motor Skills
Above average computer skills with the ability to type in order to input information into a computer.
F. Essential Physical Requirements
Ability to lift, push, carry, and file charts. Ability to sit and data entry for long periods of time.
G. Essential Mental Requirements
Ability to understand written and verbal directions in order to analyze a patient’s medical record. Ability to concentrate and pay close attention to detail for an exceptional period of work time when reviewing and analyzing records.
H. Essential Sensory Requirements
Ability to see, interpret and read medical information.
I. Exposure to Hazards