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Medical Records Coder, Sr. - Baylor Medical Center at Carrollton - HIM - Weekdays: Baylor Health Care System

Baylor Health Care System is a not-for-profit, faith-based healthcare system with many care locations in the Dallas-Ft. Worth community. The Medical Records Coder Senior codes and abstracts Inpatient, Day Surgery and Observation medical records. This position may also code and abstract ancillary and procedural outpatient medical records. Enters diagnostic and procedure codes into the coding/abstracting system and billing system as appropriate. Utilizes International Classification of Disease (ICD-9-CM) and Physicians Current Procedural Terminology (CPT) coding systems and other coding references to ensure accurate coding.

I. Analyzes and interprets inpatient, outpatient and observation medical records to ascertain complete and accurate information for coding and abstracting.

II. Determines principle diagnosis(es) and procedure(s) utilizing updated Medicare coding guidelines and other references.

III. Identifies and codes all pertinent comorbid and complicating diagnoses utilizing the encoder.

IV. Identifies and codes all applicable invasive procedures utilizing the encoder.
V. Abstracts required data into the coding and abstracting system.
VI. Optimizes DRG reimbursement by resequencing diagnoses when possible in accordance with coding guidelines.

VII. Works collaboratively with revenue cycle departments to ensure billing coding and edits are processed timely.

VIII. Serves as a resource person for the Health Information Management Department as well as other Hospital departments by answering questions related to coding issues.

IX. Provides coding backup as requested by the Management to ensure adequate chart flow.

X. Works closely with direct Manager to ensure operational needs of facility are met.

XI. Utilizes the chart management system as required by task and responsibility.

Certification:
Registered Health Info Technologist Preferred
Registered Health Info Administrator Preferred
CCS

Requirements:
High School Diploma
1 Year of Experience
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