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WI-Christian Home & Rehabilitation Center

Worker Type:

Regular

Job Summary:

Responsible for developing and maintaing medical records according to state and federal guidelines and facility policy. Completes diagnostic coding for statistical and billing purposes.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Develops and maintains diagnosis list on a daily basis.

• Completes discharge charts according to established facility procedure. Ensures all required signatures have been received.

• Abstracts pertinent information from patient records. Assigns the International Classification of Diseases, Clinical Modification (ICD), Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) codes, creating Ambulatory Patient Classification (APC) or Diagnosis-Related Group (DRG) assignments.

• Identifies all billable services through review of all applicable data sources, including but not limited to: health records, inpatient admit, discharge and transfer (ADT) reports, operative logs, nursing home visit documentation, procedure reports, etc.

• Performs other duties as assigned.

EDUCATION

• High School diploma/GED or 10 years of work experience

EXPERIENCE

• Two years' experience

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.

• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.

• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.

• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.

• Frequent keyboard use/data entry.

• Occasional bending, stooping, kneeling, squatting, twisting and gripping.

• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.

• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

• None

Work Shift:

Day Shift (United States of America)

Job Type:

Employee

Department:

8441000051 Medical Records

Scheduled Weekly Hours:

40

SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status , or any other characteristic protected by applicable law. Click here to learn more. (https://www.ssmhealth.com/privacy-notices-terms-of-use/non-discrimination?_ga=2.205881493.704955970.1667719643-240470506.1667719643)