HIM Coding Tech II | On-Site | Full Time

Job Description:

Under general direction, responsible for assigning diagnostic and procedure codes to records of outpatients, including Emergency encounters and assignment of the E & M coding, Observation, Same Day Surgery, assigning professional (profee) codes for the Hospitalist and Anesthesiologist. Performs all duties as required within the department and hospital policies and procedures. The Health Information Management Department Coding Technician II provides quality services to all customers (e.g., patients, physicians, and employees), who require assistance. Services might include physician support, billing support, audit support, document improvement (CDI), and a member of designated Committees as assigned by the HIM Director. Treats customers, peers and others with kindness and respect under all circumstances. Completes other duties as assigned.

Essential Functions:

• Codes data from patient records utilizing 3M computerized coding system to ensure optimal reimbursement to the hospital.


• Meets productivity standards


• Abstracts data from the patients’ medical record using the 3M computerized abstracting system to compile accurate and timely statistical data.


• Verifies accuracy of information by identifying such things as patient’s name, DOB, hospital billing account number, medical record number and location in hospital to ensure proper chart is processed.


• Reviews medical charts for deficiencies and completes appropriate forms as directed by Coding Manager and/or Department Manager.


• Performs other related duties as needed to support the achievement of department goals and objectives.


• Reads the Coding Clinic as received on a quarterly basis.


• Stays apprised of changes in the CPT/HCPCS, modifiers, NCCI edits, and ICD-10-CM coding nomenclatures.


• Complies with the Coding guidelines and Billing Compliance standards of GMC.


• Follow five fundamentals of patient communication: Acknowledge, Introduce, Duration, Explanation, Thank You (AIDET)


• Practices and promotes the culture of safety.


• Supports, promotes, and adheres to the Standards of Behavior.


• Adheres to the National Patient Safety Goals.


• Performs other duties as assigned.

Job Requirements:

Licenses or Certifications: Certified coding credentials are required. May have any of the following certified coding credentials: CCS, CCSP, CCS-H, CPC, or CPC-H.

Work Experience: Minimum of 2 year of previous experience

Required Knowledge or Skills: 

• Working knowledge of coding/abstraction, medical terminology, ICD-10-CM, CPT, APCs and DRGs

• Strong computer skills (Microsoft Office products)


• Effective interpersonal communication skills to acquire needed information and maintain cooperative work relationships with physicians


• Excellent communication skills


• Exceptional organizational/Time management skills, verbal and written communication skills required


• Ability to organize work priorities and meet specific objectives under time constraints


• Ability to manage multiple tasks simultaneously


• Good problem-solving skills and attention to detail


• Ability to be a team player in a team-oriented environment


• Proficient at 10 key


• Ability to use fax, photocopier, PC, microfiche reader/printer, scanner

Physical Demands:

• Lifting- Occasional: maximum of 30 lbs. from floor to chest height, 1 x year.


• Transfers: None


• Push/Pull: Minimal force required to pushcart of records, 1 x day for 300 yards.


• Carry: Maximum of 3 lbs. for 100 yards. Medical records and papers.


• Computer: 95% of day, 20% mouse, 80% data entry.


• Fine Motor: High degree for data entry, manipulations papers, clips, etc.


• Standing: Up to 1 hour at one time and 1 hour in one day.


• Sitting: Up to 3 hours at one time and 7.5 hours in one day.


• Kneeling: Up to 1 minute at one time and 20 minutes in one day.


• Stooping: Up to 1 minute at one time and 20 minutes in one day.


• Driving: None.


• Climbing: Up to 1 minute at one time and 2 minutes per day.


• Other: Constant talking, hearing, and seeing to interact with staff, physicians, patients, and vendors.

Environmental Conditions: Locations: Inside. Subject to many interruptions. Occasional pressure due to multiple calls and inquiries. Occasional pressure to meet deadlines. Requires judgment and action. May be exposed to unpleasant customers. Minimal exposure to biohazardous materials. Some exposure to cleaning chemicals and dust.