Medical Records Coding Manager supervises and trains a team of medical coders to ensure medical records are coded with accuracy and completeness. Ensures medical records coding operations follow the latest guidelines and compliance standards. Being a Medical Records Coding Manager maintains required documentation and confidentiality of patient records. Implements processes for coding operations that support the needs of other healthcare partners. Additionally, Medical Records Coding Manager develops and maintains up-to-date knowledge of the latest ICD and CPT coding versions and ensures coders receive updates and training on classification or guideline changes. Is a certified medical coder and the exact type of coding certification may vary based on the clinical setting or a medical specialty focus. Typically requires a bachelor's degree in healthcare administration, a related field, or equivalent. Depending on the setting typically requires the Certified Coding Specialist (CCS) certification. May additionally have the Registered Health Information Administrator (RHIA) credential. Typically reports to a manager or head of a unit/department. The Medical Records Coding Manager supervises a group of primarily para-professional level staffs. May also be a level above a supervisor within high volume administrative/production environments. Makes day-to-day decisions within or for a group/small department. Has some authority for personnel actions. To be a Medical Records Coding Manager typically requires 3-5 years experience in the related area as an individual contributor. Thorough knowledge of functional area and department processes. (Copyright 2024 Salary.com)
POSITION SUMMARY:
Medical Records Specialist is responsible for the entering and/or processing of documents, clinical information, and medical orders, as well as the maintenance patients' electronic records. The Medical Records Specialist also assumes duties of the Team Assistant as assigned.
MINIMUM QUALIFICATION STANDARDS:
I. Education:
High school diploma or equivalent
II. Experience:
Minimum of two years office experience, preferably in a home care environment
PERFORMANCE REQUIREMENTS:
I. Performance Standards:
* Audits and processes physician signed plans of care and interim orders ensuring that they are complete and accurate
* Receives, processes, and tracks documents such as admission forms, consent forms, Medicare Non-Coverage Notices, and Home Health Advance Beneficiary Notices
Receives, prepares, and submits both internal and external record requests
* Reminds clinicians and notifies clinical team managers of overdue or missing documentation. Contacts clinicians as needed to clarify orders and other documents
* Enters clinical data into the electronic record, including clinical notes and signed medical orders, as requested
* Corrects or assists with correcting documents according to organization's procedures
* Acts as a resource to staff and managers for questions related to interim orders, order processing, and other clinical record documents. Assists clinicians to complete orders, forms, and records in conformance with regulations
* Maintains electronic clinical records for accuracy and proper billing
* Refers non-routine questions and situations related to electronic medical records to supervisor, clinical team manager, or Accounts Receivable, in order to acquire a solid understanding of regulations and clinical record requirements
* Runs reports as assigned
* Any other duties as assigned by supervisor
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