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Required Skills

• Identifies and codes hospital all outpatient and/or inpatient records for the purpose of reimbursement, research, and compliance according to documented diagnosis(es) operation(s) and procedure(s).  Abstracts all required information in accordance with national and facility requirements.  
  • Accurately extracts clinical information from records according to established requirements using abstracting software. 
  • Meets established quality (95% DRG accuracy) and productivity (2.5 records/hr. average) standards.
  • Understands and keeps abreast of Medicare regulations that relate to coding and DRG validation and APC guidelines.
  • Interpret coding rules and general policies in addition to determining appropriate conclusions. 
  • Must be able to explain codes, terminology and coding guidelines to physicians and hospital personnel.
  • Observes confidentiality and safeguards all patient related information.
• Works with Clinical Documentation Improvement (CDI) staff to ensure complete, consistent documentation within the medical record.
  • Identifies documentation that requires clarification.
  • Works with CDI team, Coding Coordinator and/or Coding Supervisor to resolve differences between CDI and Coding.   
• Assists the Coding Supervisor and/or Coding Coordinator with the development and/or revision of policies as requested. 
  • Assist with mentoring of coding staff when requested by the Coding Supervisor and/or Coding Coordinator.
• Communicates a positive, professional manner in contacts with visitors, physicians, and hospital staff.
  • Attends continuing education classes to maintain coding proficiency in ICD-10-CM/PCS, CPT/HCPCS, ambulatory surgery, ambulatory care and other areas as deemed necessary by management.
  • Exhibits understanding of CARES and hospital mission statement.
  • Maintains a good working relationship within the department, hospital departments and with medical staff.
• Perform other job-related duties as required.

Required Skills

Essential Functions and Job Duties

· Identifies and assigns appropriate codes for the purpose of reimbursement, research, and compliance in accordance with ICD-10 and CPT coding guidelines.

o Complies with all federal, local and other legal requirements as they relate to medical coding practices.

o Reviews all inpatient, ancillary, clinic, and series accounts and assigns and sequences all diagnoses and procedure codes to the highest level of specificity documented in the provider notes.

o Observes confidentiality and safeguards all patient related information.

· Communicates in a positive and professional manner with visitors, physicians, and hospital staff.

o Maintains an optimal working relationship with peers, other hospital departments, and physicians.

o Exhibits understanding of CARES and the hospital mission statement.

o Attends continuing education classes to maintain coding proficiency in ICD-10-CM-PCS and CPT/HCPCS, and other areas as deemed necessary by management.

· Perform other job-related duties as required.

Required Skills

• Review medical records and accurately code the principal and all secondary diagnoses and procedures using ICD-9-CM, ICD-10-CM, and/or CPT coding conventions; sequence the diagnoses and procedures using coding guidelines; abstract and compile data from medical records to assign the most appropriate codes for optimal reimbursement.
• Coding of Outpatient Diagnostic Accounts- as assigned performs coding analysis on all outpatient diagnostic accounts utilizing 3M and/or other coding products. Abstracts all coded accounts in coding system per procedure.  Ensure an APC assignment is accurate.
• Participates in required continuing education and compliance training programs to maintain an understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques to support the effective application of ICD-9-CM, ICD-10-CM and CPT coding guidelines to outpatient diagnoses and procedures. Staff will maintain up-to-date knowledge of medical records practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), Centers for Medicare and Medicaid (CMS), Federal Intermediary (FI) and other related organizations. 
• Ensures compliance with all current Memorial Medical Center and department policies and procedures.
• Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:
• Demonstrates ability to cooperate with Memorial Medical Center management personnel, physicians and other persons contacted during the working day.
• Enter and retrieve patient medical data from computer terminal updating entries as necessary; audit medical record for accuracy and completeness, note deficiencies and refer for appropriate follow up and completion.
• Participates in monthly coding meeting with Coding Supervisors and other meetings at determined appropriate.
• Serve as a member of designated divisional committees and other steering committees as appropriate.
• Promotes MHS Guest Relations philosophy, Statement of Values, and follows MHS Behavior Standards and Code of Conduct.
• Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.

Required Skills

1. Reviews medical records and accurately code the principal and all secondary diagnoses and procedures using ICD-10-CM, ICD-10-PCS, and/or CPT coding conventions; sequence the diagnoses and procedures using coding guidelines; abstract and compile data from medical records to assign the most appropriate codes for optimal reimbursement.

1. Assists in the charge capture process to ensure the capture of technical and professional charges related to the healthcare services provided. Enter charges based on department documentation.  Responsible for appropriate application of charges for services provided in the Emergency Department by the physician and for resources utilized by the facility including professional fee, facility fee, procedure and supplies.

1. Performs coding of inpatient/observation accounts, as assigned by supervisor/manager, performs coding analysis on inpatient/observation accounts utilizing 3M and /or other coding products. Prepares coding summaries.  Abstracts all coded records in coding system per procedure.  Assists with post bill audit as directed by supervisor/manager.  Ensure the MS-DRG assignment is accurate.

1. Performs coding of outpatient diagnostic accounts- as assigned performs coding analysis on all outpatient diagnostic accounts utilizing 3M and/or other coding products. Abstracts all coded accounts in coding system per procedure.  Ensure ambulatory payment classification (APC) assignment is accurate.

1. Embodies the Memorial Health System Performance Excellence Standards of Safety, Courtesy, Quality, and Efficiency that support our mission, vision and values:

• • SAFETY: Prevent Harm – I put safety first in everything I do.  I take action to ensure the safety of others.

• • COURTESY: Serve Others – I treat others with dignity and respect.  I project a professional image and positive attitude.

• • QUALITY: Improve Outcomes – I continually advance my knowledge, skills and performance.  I work with others to achieve superior results.

• • EFFICIENCY: Reduce Waste – I use time and resources wisely.  I prevent defects and delays.

1. Maintains competency with coding changes. Participates in required continuing education and compliance training programs to maintain an understanding of anatomy and physiology, medical terminology, disease processes and surgical techniques to support the effective application of ICD-10-CM, ICD-10-PCS and CPT coding guidelines for outpatient diagnoses and procedures.  Staff will maintain up-to-date knowledge of medical records practices, standards, regulations, The Joint Commission (TJC), Centers for Medicare and Medicaid (CMS), Federal Intermediary (FI) and other related organizations. 

1. Ensures compliance with all current Abraham Lincoln Memorial Hospital and department policies and procedures.

1. Ensures accurate and timely coding of records, within organizational and departmental guidelines. Ensure patient confidentiality and information security according to laws and regulations governing privacy and security.

1. Communicates with Patient Accounts to resolve billing/coding matters. Demonstrates ability to cooperate with Abraham Lincoln Memorial Hospital management personnel, physicians and other persons contacted during the working day.  Works directly with physician and Allied Medical Staff to clarify coding issues.  Utilizes physician documentation query form effectively. 

1. Enters and retrieves patient medical data from computer terminal updating entries as necessary; audit medical record for accuracy and completeness, note deficiencies and refer for appropriate follow up and completion.

1. Participates in routine coding meeting with Coding Supervisor and other meetings at determined appropriate.

1. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.

Required Skills

•  Retrieves records from various departments and performs extensive search of missing records from units.

•  Creates appropriate discharge register to verify receiving of record.

•  Prepares record for scanning according to HIM processing policy and procedures.

•  Processes electronic images in the electronic medical record system according to HIM processing policy and procedures.

•  Demonstrates an ability to be flexible, organized, and function well in stressful situations.

•  Communicates and coordinates with ancillary departments, physicians, medical offices and coding.

•  Provides customer service support to patients who call or present with questions and requests.

•  Performs appropriate quality reviews according to Joint Commission regulations.

•  Ensures patient information is released appropriately with accurate authorization to patients, other healthcare organizations for continuation of care, insurance providers to ensure payment, government agencies, and in response to legal requests.

•  Performs processes in accordance with CMS guidelines.

•  Adheres to the Statement of Values and Behavioral Standards.

•  Performs other related work as required or requested.

Required Skills

•  Retrieves records from various departments and performs extensive search of missing records from units.

•  Creates appropriate discharge register to verify receiving of record.

•  Prepares record for scanning according to HIM processing policy and procedures.

•  Processes electronic images in the electronic medical record system according to HIM processing policy and procedures.

•  Demonstrates an ability to be flexible, organized, and function well in stressful situations.

•  Communicates and coordinates with ancillary departments, physicians, medical offices and coding.

•  Provides customer service support to patients who call or present with questions and requests.

•  Performs appropriate quality reviews according to Joint Commission regulations.

•  Ensures patient information is released appropriately with accurate authorization to patients, other healthcare organizations for continuation of care, insurance providers to ensure payment, government agencies, and in response to legal requests.

•  Performs processes in accordance with CMS guidelines.

•  Adheres to the Statement of Values and Behavioral Standards.

•  Performs other related work as required or requested.

Required Skills

• Follows nursing process of assessment, planning, intervention and evaluation, incorporating physical as well as psycho-social needs of designated patient populations in person, and over the telephone. Practices within professional scope and current standards of care. Applies the Minimum Necessary Standard when accessing protected health information.
• Documents according to professional scope and current standard of care ensuring that entries are complete. Reviews quality audits and makes improvements accordingly.
• Assists in various aspects of patient flow process including, but not limited to securing/stocking necessary supplies, preparing exam room and patient for examination, assisting the provider with the exam or procedure, providing treatments and medications as ordered by the provider and cleaning/disinfecting exam/treatment area after use.
• Assists with various aspects of diagnostic testing including obtaining and/or preparing specimens, labeling/recording, and communicating results. Performs miscellaneous CLIA-waived testing. May perform EKG’s/rhythm strips, spirometry, pulse oximetry, nebulizers, as well as other testing outlined by the provider.
• Assists clinic in meeting financial goals related to revenue and expense. Obtains appropriate insurance referrals and pre-certifications. Finds most cost effective means when securing/stocking necessary supplies.
• Responsible for working with team to improve processes and implement quality plans, and provide a high level of patient satisfaction.
• Demonstrates support for and participates in accomplishing team goals and objectives.
• Performs other related work as required or requested.

Required Skills

• Follows nursing process of assessment, planning, intervention and evaluation, incorporating physical as well as psycho-social needs of designated patient populations in person, and over the telephone. Practices within professional scope and current standards of care. Applies the Minimum Necessary Standard when accessing protected health information.
• Documents according to professional scope and current standard of care ensuring that entries are complete. Reviews quality audits and makes improvements accordingly.
• Assists in various aspects of patient flow process including, but not limited to securing/stocking necessary supplies, preparing exam room and patient for examination, assisting the provider with the exam or procedure, providing treatments and medications as ordered by the provider and cleaning/disinfecting exam/treatment area after use.
• Assists with various aspects of diagnostic testing including obtaining and/or preparing specimens, labeling/recording, and communicating results. Performs miscellaneous CLIA-waived testing. May perform EKG’s/rhythm strips, spirometry, pulse oximetry, nebulizers, as well as other testing outlined by the provider.
• Assists clinic in meeting financial goals related to revenue and expense. Obtains appropriate insurance referrals and pre-certifications. Finds most cost effective means when securing/stocking necessary supplies.
• Responsible for working with team to improve processes and implement quality plans, and provide a high level of patient satisfaction.
• Demonstrates support for and participates in accomplishing team goals and objectives.
• Performs other related work as required or requested.

Required Skills

• Professionally and courteously, interact with the general public, physicians and hospital personnel.
• Receive Physician orders for patient testing and ensures orders comply with Medicare’s Local Coverage (LCD) and National Coverage Decision’s (NCD).
• Obtain patient clinical and demographic data to appropriately provide the medical service identified by the practitioner and to provide the service at the time that best meets the patient schedule.
• Keeps unit stocked in necessary supplies and keeps work area neat and organized.
• Plays a vital role in representing JMH in a positive, compassionate manner with professional communication, mannerism, and appearance.
• Assist patients/visitors throughout the enterprise, providing telephone support, one-on-one assistance and way finding.
• Maintains a cooperative and productive working relationship with all co-workers, physicians, management, and external customers to coordinate for optimum patient flow and throughput.
• Actively supports patient/family centered care by actions and attitude that demonstrates service excellence.
• Identifies customer service concerns and resolves and/or initiates service recovery.
• Accountable for coordinating patient scheduled services, insurance authorization, benefits verifications and to ensure accurate demographic/financial data is properly obtained, entered, and documented into required system(s). Initiates the Patient Revenue Cycle by proper identification, verification and entry of insurance and authorization information.
• Notifies and explains financial obligation to the patient/guarantor in a compassionate manner.
• Provides resources for financial assistance.
• Stays abreast of insurance and billing codes updates.
•  Issues and explains insurance waivers, as necessary.
• Demonstrate a good understanding of the elements involved with the various procedures/exams and provide appropriate instructions to patients for specific testing ordered.

Required Skills

1. Interprets, orders, and generates barcode labels from the Lab LIS system and applies labels to appropriate specimen tubes and collection containers. Must be able to interpret many different physician orders and requests to include over 1800 lab tests and select the appropriate orderable code in the Lab LIS system.

1. Removes biological specimens from biohazard bags including blood, urine, bone marrow, body fluids, and tissue specimens. Understand all different types of collection media, preservatives, and risks of exposure to infectious agents. Handles both infectious A and B substances with appropriate CDC, and IDPH guidelines. Ability to determine if specimen was collected in appropriate collection container and media. Understands steps to resolve collection issues to ensure patient testing is performed or recollected.

1. Receives all calls arriving in the laboratory from providers, clients, nurses, management, and patients. Logs calls in tracking software, answers all questions pertaining to phlebotomy draws, specimen collection, transport of specimens, provides lab results, supply requests, forensic autopsy cases, and administrative questions. Escalates callers to management or technical departments when necessary if unable to resolve all question  

1. Correctly enters outpatient and non-patient demographic, insurance, and diagnosis information into the hospital registration system, answering all questions in each field and updating any information that is not current. Understands insurance policy numbers and carrier codes including client account versus patient insurance billing. Recognizes valid diagnosis codes and follows appropriate resolution on any noncompliant codes.

1. Monitors the printing of physician reports for inpatients and outpatients. Separates lab reports for delivery to the correct ordering provider or client site to ensure providers receive lab results in a timely manner.

1. Communicates requests for specimen collection to phlebotomists in a timely and appropriate manner. Works closely with phlebotomy staff and managers to organize and facilitate inpatient and outpatient phlebotomy requests.

1. Inputs all faxed orders into the lab orders database, questioning any illegible order, calls physician’s office with clarification of test order and patient demographics and order request (standing or one time).  Follows all instructions on provider order including, add on testing and testing cancelations. Understands how to handle a verbal order request from a provider and documents correctly.

1. Schedules all fine needle aspirates and biopsies as requested by clinicians, ensures a pathologist is dispatched when clinician is ready to perform procedure.

1. Processes all slide and block requests for internal and external consultations, including preparing appropriate paperwork, requesting material, pathologist review and sign off, shipping, and material returns.

1. Assists with the preparation of slides and blocks for sendout testing.  

1. Contribute to departmental operations by performing other related duties as may be required and/or assigned.
2. Monitors the laboratory computer system operations menu to ensure all operations are running and respond to the appropriate prompts to print daily reports. Notify appropriate computer operations staff concerning exceptions.

1. Maintains and scans patient records according to government regulations and accreditation guidelines.

1. Ensures that professional and personal activities conform to Memorial Medical Center strategic plan and philosophy regarding the Guest Relation Program.

1. Performs other related work as required or requested.

The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by incumbents of this job.  Incumbents may be requested to perform tasks other than those specifically presented in this description.