Coder/HIM Specialist analyzes and abstracts clinical data by assigning codes from the patient records in accordance to coding classification systems. Reviews patient encounters, queries physicians when needed, and identifies and reports issues. Assigns ICD-10-CM codes, creates DRG group assignments. Ensures that codes are accurate and relevant to the patient encounter. Codes inpatient, partial hospitalization, and outpatient charts. Prepares and submits charts required for Precyse Medicare audits.
HIM Specialist/ physician Liaison: is responsible for assembly and analysis of discharge medical records. Reviews records for completeness, accuracy and compliance with regulations. Compiles, processes, and maintains records in a manner consistent with medical, administrative, ethical, legal, and regulatory requirements of the health care system. Maintains filing of medical records and assists with Release of Information. Maintains and operates a variety of health records indexes and storage retrieval systems to index, classify, store and analyze information. Assists the HIM Director in the training and supervising of interns and light duty staff.
Responsible for daily transcription duties which may include the following; printing from precision transcription electronic system. Corrections, observing and noting date and time in dictation reports, deliver to unit and accurate medical record.
Maintains and preserves daily electronic reports (i.e.: MIDAS, MS4, excel, Precision Scribe) of psychiatric evaluations, Health & Physicals, and Discharge summaries for Health Information Management department to be within ordinance of policies, procedures and compliancy rates.
Sustains daily, weekly, monthly communication of dictation requirements with physicians via courtesy notifications to ensure department is within all regulatory requirements.
Upholds a positive rapport with all physicians and physician offices, and assists them when needed. Cross trains with other staff in the department to ensure that all work flow is efficient.