Specialty Coder - Medical Records

DepartmentMedical Records

ScheduleFull Time, 40 Hours, Days

FacilityCentral Maine Medical Center

LocationLewiston, Maine, 04240

Central Maine Healthcare is an integrated healthcare delivery system serving 400,000 people living in central, western and Midcoastal Maine. CMH's hospital facilities include Central Maine Medical Center in Lewiston, Bridgton Hospital and Rumford Hospital. CMH also supports Central Maine Medical Group, a primary and specialty care practice organization. Other system services include the Central Maine Heart and Vascular Institute, a regional trauma program, LifeFlight of Maine's southern Maine base, the Central Maine Comprehensive Cancer Center and other high-quality clinical services.

The Specialty Coder reviews and analyzes documentation present in the medical record for both inpatient and outpatient visits to ensure accuracy of diagnosis and procedure codes assigned by the Coders or Clinical Documentation Specialists (CDS) or Computer Assisted Coding (CAC) software. Coder Auditor finalizes the coding and abstracting of the medical record upon ensuring the assignment of International Classifications of Diseases, Ninth Revision (ICD-9-CM) or Tenth revision (ICD-10/PCS), Current Procedural Terminology (CPT), and Health Care Procedure Coding System (HCPCS), are accurate and supported by the clinical documentation of the respective medial record. Holding a senior coding position, assumes primary responsibility for DRG validation/accuracy, primary role in assisting CDS and medical staff members with improving quality of clinical documentation. Participates in chart review projects as assigned and other duties as needed.

1. High school graduate or equivalent.
2. CCS required.
3. 1+ year of clinical experience in acute care setting preferred.
4. Must meet the performance standards set forth by the Hospital/ Department at Coder Auditor position for at least 6 months.
5. Minimum of two years' experience with ICD-9 and CPT coding in an acute care setting preferred.
6. Basic computer experience required.
7. Use of an encoder software product for code assignment in an acute care setting required
8. Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm preferred
9. Excellent written and verbal communication skills. Excellent critical thinking skills.
10. Excellent interpersonal skills to build effective partnering relationships with physicians, nurse staff, coding staff and hospital management staff.
11. Ability to work independently in a time-oriented environment.
12. Computer literacy and familiarity with the operation of basic office equipment.

Full Time

Days

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