Coder I - Medical Records

Overview

Department: Medical Records

Schedule: Full Time, 40 Hours, Days

Facility: Central Maine Medical Center

Location: Lewiston, 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.

 

Responsibilities

The Coder I reviews and analyzes documentation present in the medical record for both inpatient and outpatient visits to determine diagnoses and procedures as described by the physicians of record. Utilizing the International Classifications of Diseases, Ninth Revision (ICD-9) and Current Procedural Terminology (CPT), the Coder I translates the documented diagnosis and procedural information into coded data. Determination of code assignment is based on the official American Health Association (AHA) guidelines in addition to hospital specific and regulatory guidelines. The Coder I enters the coded data and other abstracted data from the medical record into hospital's electronic information system, facilitating the Health Information Services department's indexing responsibility for internal use (such as to support medical care evaluation studies), and mandated reporting requirements. Participates in chart review projects as assigned.

Qualifications

Minimum one year experience with ICD-9 and CPT coding in an acute care setting; required.

Basic computer experience; required.

Use of an encoder software product for code assignment in an acute care setting; preferred.

Computer data entry with 10-key preferred, with accurate typing speed of 35 wpm; preferred.

Successful completion of college level courses in anatomy, physiology, medical terminology, and coding ICD and CPT; required.

Successful completion of or current enrollment in a program for certification as a Certified Coding Specialist (C.C.S.), Registered Health Information Technician (R.H.I.T.), or Registered Health Information Administrator (R.H.I.A.); required.

Certification or license as a Certified Coding Specialist (C.C.S.), Registered Health Information Technician (R.H.I.T.), or Registered Health Information Administrator (R.H.I.A.); preferred.

 

Employment Status

Full Time

Shift

Days

Equal Employment Opportunity

Company is an equal employment opportunity employer. Company prohibits discrimination against any applicant or employee based on race, color, sex, sexual orientation, gender identity, religion, national origin, age (subject to applicable law), disability, military status, genetic information or any other basis protected by applicable federal, state, or local laws. The Company also prohibits harassment of applicants or employees based on any of these protected categories. Know Your Rights: https://www.eeoc.gov/sites/default/files/2022-10/EEOC_KnowYourRights_screen_reader_10_20.pdf