Sree Balaji Medical College & Hospital
Urgently Required
Medical Records Technicians (HIM)
Experience : 1 to 5 years
No of vacancies : 1
Job Description: Medical Records Technicians, often known as Coders in the healthcare industry, play a crucial role in managing patient health information and ensuring that medical services are coded accurately for billing, reporting, and analysis purposes. These professionals are responsible for converting healthcare providers’ diagnoses, treatments, and procedures into universal medical alphanumeric codes. They ensure that health records are complete, accurate, and accessible while maintaining patient data confidentiality.
Key Responsibilities: Coding and Classification: Accurately assign and sequence diagnostic and procedural codes according to patient medical records using ICD-10-CM, CPT, and HCPCS coding systems.
Medical Records Review: Review patients’ records for timeliness, completeness, accuracy, and appropriateness of health data.
Compliance and Quality Control: Ensure coding compliance with regulations and guidelines, including HIPAA; perform audits to validate code assignment and improve quality.
Collaboration with Healthcare Providers: Work closely with physicians and other healthcare providers to clarify diagnoses or obtain additional information for accurate coding.
Data Management and Reporting: Use electronic health record systems to enter coding data and assist in the management of health information.
Education and Training: Stay updated with changes in coding standards, guidelines, and regulations by participating in continuing education and training sessions.
Billing and Reimbursement Support: Collaborate with billing departments to assist in the reimbursement process and resolve any discrepancies related to coding.
Education Qualifications: Educational Background: High school diploma required; an Associate’s degree in Health Information Technology or a related field is preferred.
Certifications: Certification from the American Health Information Management Association (AHIMA) or the American Academy of Professional Coders (AAPC) is highly desirable. Examples include Certified Professional Coder (CPC) and Certified Coding Specialist (CCS).
Experience: Prior experience in medical coding or a related field is beneficial, though entry-level positions may not always require it.
Skills and Competencies: Proficiency in medical terminology, anatomy, and physiology; understanding of the ICD-10-CM, CPT, and HCPCS Level II coding systems; attention to detail; strong analytical skills; and ability to maintain confidentiality.
Key Attributes: Detail-Oriented: Exceptional attention to detail to accurately code patient records and ensure compliance with coding standards and regulations.
Analytical Skills: Ability to interpret and analyze medical records and health information.
Integrity: Strong ethical standards to handle sensitive and confidential patient information responsibly.
Adaptability: Willingness to continuously learn and adapt to changes in coding guidelines and healthcare regulations.
Communication Skills: Effective communication skills to interact with healthcare providers and clarify information for accurate coding.
About the Role: Data Quality Guardian: Ensures the accuracy and integrity of patient health information, which is critical for patient care, billing, and reporting.
Revenue Cycle Contributor: Plays a pivotal role in the healthcare revenue cycle by ensuring services are coded accurately for appropriate reimbursement.
Compliance Advocate: Helps healthcare organizations comply with medical coding standards and regulations, thereby avoiding legal and financial penalties.
Health Information Educator: May serve as a resource for healthcare providers, offering guidance on best practices for documentation to ensure accurate and compliant coding.
Data Analyst Assistant: Supports health information data analysis by providing accurately coded data, which can be used for healthcare planning, quality assessment, and research.
Medical Records Technicians/Coders are essential to the functionality of healthcare operations, bridging clinical practices with billing and administrative processes, ensuring the financial viability of healthcare providers, and contributing to high-quality patient care through accurate data management.