Job Description:

• Review Physician dictation and transcribe to clinical notes in EMR/Billing systems.

• Prepare and assemble medical record documentation/charts for physician(s).

• Ensure medical record compliance by self-documentation attestation.

• Update patient history, physical exam, and other pertinent health information in the patient.

• Prepare and send all documentation to physician for review and approval via authentication of detailed data entry and facility-specific procedures.

• Monitor the duration of basic lab results and screening procedures.

• Comply with hospital and medical facility policies, including those relating to HIPAA and Joint Commission.

• Perform other clerical duties and tasks to improve provider productivity and clinic workflow as assigned.

• Assign codes to diagnoses and procedures, using ICD (International Classification of Diseases) and CPT (Current Procedural Terminology) codes.

• Ensure codes are accurate and sequenced correctly in accordance with government and insurance regulations.

• Follow up with the provider on any documentation that is insufficient or unclear.

• Communicate with other clinical staff regarding documentation.

• Search for information in cases where the coding is complex or unusual.

• Receive and review patient charts and documents for accuracy.

• Review the previous day's batch of patient notes for evaluation and coding.

• Ensure that all codes are current and active.

Job Qualifications:

• Bachelor's degree with pre-health career track preferred.

• Strong knowledge of anatomy, physiology, and medical terminology.

• Familiarity with ICD-9 codes and CPT Procedures.

• Skilled in operating various medical record software and hardware, word-processing, and database software programs.

• Proficiency in using Microsoft Office applications.

• Administrative writing, reporting, record-keeping, and typing skills.

• Strong organizational skills

• Professional, and has good confidentiality skills.

• Excellent oral and written communication skills

• High School diploma, GED, or associate degree or certification in Medical Coding is a plus