Job Description

Position Description

Clinic Coder and Medical Records Clerk

Job Responsibilities Understands, promotes and follows the Mission and Guiding Values of the Petersburg Medical Center.

Assures quality care through billing/coding, medical records and patient services through the following responsibilities:

Coder: Generates census of daily office visits. Follows CPT and ICD 10 guidelines for coding clinic charts. Reviews and corrects clinic coding discrepancies. Communicates with clinic staff- registration, providers and medical assistants- when a discrepancy is identified to correct. Communicates with Business Office and HRG for coding and billing issues

Data Abstraction: Generates reports as needed for clinic coding.

Chart Reviewer: Reviews clinic charts for completeness and communicates deficiencies. Reviews charts for appropriate release of information (ROI) of sensitive records.

Filing/Scanning:Scans and uploads records into electronic health record as needed.

Release of Information: Review and release information as appropriate for subpoenas and requests by patients, healthcare facilities, lawyers, insurance companies, Social Security Administration, and others as needed:

1. In charge of all requests for release of records and works closely with and cross cover the Clinic Medical Records Assistant and Hospital Medical Records Clerk.
2. Must understand and follow HIPPA and HITECH laws.
3. Copies and sends charts by mail, manual and electronic fax, portals, encrypted email and in person.
4. Determines type of record requests, and handles them as appropriate ensuring all necessary forms have been completed and are on file.
5. Submits charge sheets for records requests to billing office.
6. Navigates and finds information as requested in electronic health records and paper records. Files charts once request is completed.
7. Keeps track of disclosures of information through logging systems.
8. Requests records as needed from other healthcare facilities to aid in patient care.
9. Performs file maintenance by thinning inactive and deceased patient charts, shredding as needed, and following proper procedures.
10. Performs additional duties as assigned.

Education: An associate degree or two year minimum with medical coding and medical records experience in a healthcare environment preferred, but not required.

Computer experience helpful, especially MS Excel, MS word, MS Outlook. Type minimum of 40 wpm preferred.

Able to deal with high demand, fast paced, multi departmental hospital needs, The individual must be highly organized, task oriented, with a high attention to detail.

Must possess the ability to prioritize responsibilities and handle multiple requests simultaneously.

Accountability

This position reports to the Medical Records Director. This person must be able to hold in confidence all that pertains to the Patient, Resident, their family, and all fellow employees.

Type: Full-time

Expires: 05/31/2025

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