JOB TITLE/CLASSIFICATION …… HEALTH INFORMATION TECHNICIAN, III (576)
DEPARTMENT ………………………… HEALTH INFORMATION SERVICES
STATUS ………………………………….. NON-EXEMPT
RELATIONSHIPS
Reports to ……………………………….. MANAGER, HEALTH INFORMATION SERVICES
POSITION SUMMARY
Under general supervision, is responsible for coding and abstracting inpatient and outpatient medical
records according to established standards.
ESSENTIAL DUTIES
Codes diseases inpatient and outpatient operations using various coding systems by transferring verbal
descriptions of diseases and procedures into numerical designations.
Abstracts selected information from each discharged patient’s medical record and records this
information on an automated case abstract.
Optimizes hospital reimbursement through selection of the correct principal diagnosis, additional
diagnoses and procedures, and grouping them according to HCFA guidelines. Maintain compliance
with federal and state regulations relative to fraud and abuse.
Screens medical records as directed by medical staff, administrative, and other department criteria.
Assists the medical staff in the development of audit criteria.
Act as liaison in implementing coding/abstracting changes, updates, etc., for various departments and
committees.
Verifies diagnosis and procedure codes on medical records held over for internal quality improvement
Process re-bills for medicare patients
Monitors the APC list for verification and accuracy of CPT codes
Other Duties
Performs other job related duties as assigned by the Manager, HIS
QUALIFICATIONS
*License/Certifications
RHIT or Coding Certified Specialist required
*Proof of required License(s) and/or Certification(s) due at time of hire.
**Education
Associate Degree in Health Information Technology
**Proof of required educational level(s) due at time of hire.
Experience
One year experience coding in an acute care and skilled nursing care facility in Health Information
Services Department, using ICD-9-CM and CPT-4
Skills
Knowledge of hospital quality assurance concepts and practices
Knowledge of DRG and APC systems
Ability to code all levels of inpatient, outpatient surgery and ER/OP cases
Ability to interact with medical staff relative to clarification of clinical diagnosis and procedures
Ability to communicate and respond with the business office staff related to billing and reimbursement
issues
