Under general supervision, this position assigns diagnostic codes to medical record information and codes charts using ICD-9-CM and HCPCS systems for statistical reporting and DRG assignment. The role abstracts required data into the hospital abstracting system to support reimbursement of hospital claims.
Key Responsibilities
- Abstract and code diagnoses, operations, and procedures from health records using established classification systems and procedures.
- Prepare statistical reports required by legal, accrediting, licensing, and hospital policy requirements.
- Assign patient severity of illness index ratings, supplemental codes, and related data.
- Compile data from health records and computer systems for quality of care evaluation and utilization review.
- Monitor completion of medical records according to time standards.
- Audit incomplete records and prepare delinquency reports.
- Confer with physicians, nurses, and other healthcare personnel to ensure complete and accurate medical records.
- Maintain logs, reports, statistical records, and health data indexes.
- Operate computer systems to process, store, and retrieve health information.
- Assist with locating medical records needed for research.
Requirements & Qualifications
Qualifications
- Associate degree in medical information technology or equivalent education/experience.
- Six months to one year of related experience and/or training, or equivalent combination of education and experience.
- Ability to perform concurrent chart review for proper DRG estimations and reimbursement.
- Knowledge of Medicare, Medicaid, and other insurance reimbursement guidelines.
- Coursework in medical terminology, anatomy, physiology, disease processes, ICD-9-CM coding, and prospective payment.
- RHIT, RHIA, or CCS required.
Location
Texas, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
1 week ago
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