Medical Records with Coding

Job title: Medical Records Clerk with Coding

Reports to: Health Information Manager

Position: Full-Time (40hr per week)

Benefit Eligible: Yes

Position Summary

The Medical Records Clerk completes analysis and filing of all medical records and reports in a timely and accurate manner. Compiles statistical information as requested for the Cherry County Hospital and Clinic. Accurately codes all patient encounters, processing record releases in accordance with hospital, state and federal guidelines.  

Duties and Responsibilities

Regular responsibilities include but are not limited to the following:

• Completes clerical duties including answering phones, responding to emails and processing patient information
• Compiles statistical reports and assists in maintaining logs as required by hospital policy or state and federal regulations
• Completes birth certificates 
• Retrieves records for physicians and other hospital staff
• Ensure patient charts, paperwork and reports are accurate and completed in a timely manner
• Notes deficiencies to be completed by physician and other professional staff
• Scanning medical records and other information into the electronic records system
• Maintains patient and department confidentiality
• Maintains medical staff appointment files per hospital policy
• Attends workshops and hospital in-service as requested
• Process requests for medical records made through the organization, patients and affiliates per hospital policy
• Review clinical documentation and assign codes to diagnoses and procedures using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes
• Communicate with healthcare providers to obtain missing information or clarify details in clinical records
• Assist the billing department with claim denials related to diagnosis or procedure coding
• Ensure all ICD Diagnosis Codes and CPT codes are assigned correctly and sequenced appropriately as per government and insurance regulations and current coding guidelines
• Ensures the confidentiality of patients’ medical, personal, and financial records is maintained
• Knowledgeable of and committed to practicing Corporate Compliance policies and procedures
• Complies with Cherry County Hospital personnel policies
• Performs other duties as assigned by the supervisor

Skills and Abilities Required

• Numerical and clerical ability to make statistical computations
• Keyboarding and computer skills
• Good communication skills
• Ability to exercise independent judgement 
• A preference for adjusting and adapting to the ever-changing rules and regulations of the Hospital and Federal Government
• Ability to treat records without emotional involvement
• Ability to work closely and cooperatively with department personnel, administration, physicians, business office, nursing, x-ray, physical therapy, laboratory, respiratory therapy, quality assurance, infection control, and various other departments, and the public
• Must be able to keep hospital and patient information confidential
• Must be knowledgeable of state and federal confidentiality laws, including but not limited to HIPAA, and be familiar with and follow all policies, procedures and instructions regarding the privacy and security of protected health information applicable to the position

Physical Demands and Working Conditions

• Requires sitting for long periods of time, standing, and bending when filing and lifting stacks of records
• Environment requires working in close proximity with others in a clean favorable area
• On-call hours required

We would also like to highlight our Comprehensive Benefit Package, which includes:

• Health Insurance: Co-pay or HSA plan options with 100% coverage for the Employee
• Dental Coverage: 100% coverage for the Employee
• Vision Coverage: 100% coverage for the Employee
• $50,000 Group Life Insurance with AD&D
• Long-Term Disability Coverage: 100% coverage for the Employee
• Medical and Dependent Care Flexible Spending Accounts
• Health Savings Account with employer contribution
• Supplemental Insurances: Short-Term Disability, Supplemental Life and AD&D, Critical Illness, Hospital Indemnity, and Accident
• Retirement Plan: 457 plan with Pre-Tax and Roth options

Direct reports

This position has no direct reports.

Minimum Job Requirements

• High School Diploma or GED
• Keyboarding and computer skills
• Completion of medical terminology course preferred or willing to complete a medical terminology course within one year of hire 
• Prior experience with medical coding or willing to complete a medical coding course within one year of hire