Medical Records Administration Specialist
Full-time
Others
Naval Medical Center, San...
7 months ago
Review and abstract inpatient chart documentation to include histo.....
- Review and abstract inpatient chart documentation to include history and physicals, progress notes, consultations, operative reports and discharge summaries
- Apply the appropriate International Classification of Disease (ICD-10), Current Procedural Terminology (CPT), Healthcare Common procedure Coding System (HCPCS), Evaluation and Management (E and M) and Diagnostic Related Groups (DRG) coding.
- Identify the appropriate Evaluation and Management based on the type of professional services rendered.
- Adhere to coding practices prescribed by the Department of Defense (DoD), Defense Health Agency (DHA), The Joint Commission (TJC), American health Association (AHA) Coding Clinic and Center for Medicare and Medicaid Services (CMS) coding guidelines.
- Enter codes using MHS Genesis software, the 3M Clinical Coding Editor (CCE) or applicable systems.
- Maintain daily productivity reports including completed activity, all metrics and incomplete activities.
- Confirm that the correct patient data is contained in the medical record to ensure that incorrect demographics are not entered into a file. Name, social security number or DoD ID number and dates of services are verified.
Starting at $64,722 Per Year (GS 9)
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