Coder Medical Records Resume Sample
Luella Romaguera
47428 Schulist Ports,
Houston,
TX
+1 (555) 768 3107
Work Experience
Senior Medical Records Coder
07/2016
-
PRESENT
Los Angeles, CA
- Consults with medical providers to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes. Provides thorough, timely and accurate review of ICD9 and/or CPT4 code assignments
- Provides quality assurance for medical records. For all assigned records and/or areas assures compliance with coding rules and regulations according to regulatory agencies for state Medicaid plans, Center for Medicare Services (CMS), Office of the Inspector General (OIG) and the Health Care Financing Administration (HCFA), as well as company and applicable professional standards
- As assigned, compiles daily and monthly reports; tabulates data from medical records for research or analysis purposes
- Acts as a knowledge resource to clinical staff for billing code issues
- Performs all functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides all customers with an excellent service experience by consistently demonstrating our core and leader behaviors each and every day
- Consults with medical providers to clarify missing or inadequate record information and to determine appropriate diagnostic and procedure codes. Provides thorough, timely and accurate review of ICD and/or CPT code assignments
- Acts as a knowledge resource to peers within the coding team as well as clinical staff for billing code issues
- Coding, charge entry review : Serve as a liaison between external coding company and billing office to maintain communication and verify that charts are coded timely and accurately by outside coding company
- Coding Questions:Under the supervision of the billing manager, research and answer any coding related questions that arise or have the potential for adverse effect on revenue.Serve as a liaison to outside coding company and billing staff to resolve billing issues related to coding or compliance.Work with providers as needed to clarify questions and educate on documentation requirements
Medical Records Technician Coder
02/2012
-
01/2016
Chicago, IL
- Adheres to accepted coding practices, guidelines and conventions when choosing appropriate diagnosis, operation, procedure, etc.
- Accepts the need for change and willingly adjusts to new work processes
- Positively handle challenges and diverse approaches to work and develops solutions to problems
- Uses thorough knowledge of coding systems and grouper logic to assign appropriate codes and DRG/APC assignment taking into consideration service intensity weights to assign optimal DRG/APC.Understands third party payers to enable selection of appropriate grouper
- Evaluating the performance of staff
- Approving sick and annual leave requests
- Identifying educational or training needs
- Coordinating human resources related matters
- Accurate and complete assignment of ICD-9, CPT-4 and modifier codes to radiology exams
Practice Medical Records Coder
09/2007
-
01/2012
Phoenix, AZ
- Maintain up to date knowledge of new medical technology, official coding rules, NCCI edits and LCD’s, and all third party payor guidelines. Participate in continuing education opportunities
- Comply with all HIPAA and Compliance standards
- Maintain and utilize expertise of all billing systems, coding systems, and PACs systems used at UR
- Continuously maintain a quality average consistent with the departmental coding standards
- Using Computer Assisted Coding software, perform review of radiology exams for all UR affiliates and modalities and assign appropriate codes
- Review, research and correct insurance company coding denials. Assist the collection staff and Coding Lead with appeals related to coding denials
- Communicate with physicians verbally or in writing when diagnostic or procedural information appears questionable or contradictory in order to clarify as appropriate
- Assist the department charge entry staff with coding questions as needed
Education
University of Mount Union
2001 - 2006
School's Degree in Health
Professional Skills
- Selects and assigns codes from the current version of several coding systems to include the International Classification of Diseases-Clinical Modification (ICD-9-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPS)
- Adheres to accepted coding practices, guidelines and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding
- Demonstrates a commitment to excellent customer service at all times
- One year of experience comparable to the next lower grade level (GS-7)
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services
- Performs a comprehensive review of the patient record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture
- Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing
How to write Coder Medical Records Resume
Coder Medical Records role is responsible for health, general, medical, terminology, training, organization, coding, education, supervision, technology.
To write great resume for coder medical records job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Coder Medical Records Resume
The section contact information is important in your coder medical records resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Coder Medical Records Resume
The section work experience is an essential part of your coder medical records resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous coder medical records responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular coder medical records position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Coder Medical Records resume experience can include:
- Participate in webinars, conferences, e-learning and other educational opportunities in order to maintain and further knowledge of radiology studies and general coding guidelines
- Skilled at using Cigna-HealthSpring coding systems (i.e., ApplicationXtender, OSCR, Lumeris, etc.)
- Skill in applying current coding classifications to a variety of specialty care areas to accurately
- Flexibility to perform coding functions or cross-cover coding areas at Strong Memorial (SMH), Highland Hospital (HH) and FF Thompson (FFT) as needed
- Performs coding audits and utilizes results to identify processing inadequacies and re-educate coding staff as necessary
- Ensures adequate auditing of coding activities
Education on a Coder Medical Records Resume
Make sure to make education a priority on your coder medical records resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your coder medical records experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Coder Medical Records Resume
When listing skills on your coder medical records resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical coder medical records skills:
- Expertly searches the patient record to find documentation justifying code assignment based on an expanded knowledge of the organization and structure of the patient record
- Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the National VA Database in Austin, TX
- Perform coding work requiring independent judgment with speed and accuracy
- Keeps abreast of regulatory changes affecting code assignments required by the Health Care Financing Administration (HCFA)
- Certified Coding Specialist (CCS) Hospital Coding Certified Professional Coder (CPC)
- Homecare Coding Specialist-Diagnosis (HCS-D) Homecare Coding
List of Typical Experience For a Coder Medical Records Resume
1
Experience For Medical Records Technician Coder Resume
- Maintaining up-to-date knowledge of new medical technology, official coding guidelines, and inpatient and outpatient prospective payment systems
- Works with collectors to resubmit claims timely and accurately, and address coding questions
- Provides billing providers and staff with information relative to coding and compliance to avoid losses in revenues. Resolves staff billing questions related to coding or compliance timely and accurately, and monitors for satisfactory resolution of all items on a weekly basis, that arise, or have the potential for adverse effects on revenue
- Distributes completed data to charge entry staff to input, and insures integrity of data prior to transmission. Researches and resolves coding denials and edits, and provides clinical analysis as requested
- Prepares reports as requested and related clerical tasks including timely reconciliation and monitoring of outstanding charts. Responsible for maintaining required CEU's and ongoing knowledge of new/current coding guidelines
- Accurate and complete assignment of ICD-9-CM/ICD-10-CM, CPT-4, and HCPCS codes to inpatient, outpatient and emergency department visits
2
Experience For Senior Medical Records Coder Resume
- Uses thorough knowledge of coding systems and grouper logic to assign appropriate codes and DRG assignment taking into consideration service intensity weights to assign optimal DRG. Understands third party payers to enable selection of appropriate grouper
- Assigns appropriate coding using thorough knowledge of coding systems, compliance guidelines and edit logic to assign appropriate codes. Understands third party payer regulations, and coding guidelines, to enable selection of appropriate codes and sequencing, including modifier assignments, CCI edits, and bundling nuances. Works to resolve issues with providers and collection staff
- Assists facility staff with documentation requirements to completely and accurately reflect the patient care provided; provides technical support in the areas of regulations and policy, coding requirements, resident supervision, reimbursement, workload, accepted nomenclature, and proper sequencing. Insures provider documentation is complete and supports the diagnoses and procedures coded
List of Typical Skills For a Coder Medical Records Resume
1
Skills For Medical Records Technician Coder Resume
- Monitors ever-changing regulatory and policy requirements affecting coded information for the full spectrum of services provided by the Medical Center
- Accurately follows coding guidelines
- Communicate with staff and supervision, both in person, in writing and over the telephone, in a tactful manner
- Follow Cigna-HealthSpring and departmental policies and procedures
- Expertise in ICD-9-CM/ICD-10-CM coding and guidelines
- Very knowledgeable of physician-specific regulations and polices related to documentation and coding
- Very knowledgeable of Medicare Risk Adjustment and specifically 360, Enhanced Encounter and HMR coding
- Registered Health Information Administrator (RHIA) Hospital Coding
- Registered Health Information Technician (RHIT) Hospital Coding
2
Skills For Senior Medical Records Coder Resume
- Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the National VA Database within established timelines
- Orients and instructs new personnel and/or students from affiliated health information or medical record technology programs, at the direction of the supervisor, on unit operations, coding, abstracting and use of an electronic medical record
- Works within a team environment; supports peers in meeting goals and deadlines; flexible and handles multiple tasks; works under pressure; and copes with frequently changing projects and deadlines
- Comprehensive knowledge of classification systems, such as current versions of International
- Supplies correct ICD-9-CM/ICD-10-CM diagnosis codes on all diagnoses provided
- Work independently to accomplish assigned work within the allocated time
3
Skills For Supervisory Medical Records Technician Coder Resume
- Treats customers with dignity/respect
- Supervises Coders in a multi-level care medical center
- Works closely with the supervisory staff of the Health Information Management Service (HIMS), Automated Data Processing Applications Coordinator (ADPAC), and Clinical Applications Coordinators (CAC), as well as other service care line managers and employees within the facility
- Serves as overseer and coordinator of the HIMS Coding Program
- Functions as the technical expert in documentation requirements for correct code assignment and resident supervision
- Contributes to the organization's mission and goals by assisting in the planning, development, implementation, and maintenance of a facility-wide coding compliance program
- Serves as a primary source to the Business Office Service and all clinical services/sections for the Diagnosis Related Group (DRG), Ambulatory Payment Classifications (APC), as well as other disease and procedure classification systems
- Applies current Uniform Hospital Discharge Data Set (UHDDS) definitions for code assignment
4
Skills For Medical Records Senior Coder Resume
- Maintains continuous monitors to ensure that recurring special data collection projects delegated by the facility are submitted in an accurate and timely manner
- 0675 Medical Records Technician
- Physical Requirements. Defined by VA Directive and Handbook 5019
- Meet the below listed grade requirements
- Experience/Education Combination. Equivalent combinations of experience and education are qualifying. The following educational/training substitutions are appropriate for combining education and experience
- At least two years of coding experience
5
Skills For Practice Medical Records Coder Resume
- Current Medical Coding Certification required (i.e., Certified Professional Coder (CPC), Certified Coding Specialist for Providers (CCS-P), Certified Coding Specialist for Hospitals (CCS-H), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA))
- Demonstrated to be detail oriented, self-motivated, and have excellent organization skills
- Measles and Rubella immunization required for selectees born after 1957. Seasonal Influenza immunization is required for civilian health care facility staff working in Indian Health Service health care facilities
- Analyze the medical record to identify all pertinent diagnoses and procedures for coding, and evaluate the adequacy of the documentation. This includes the ability to read and understand the content of the medical record, the terminology, the significance of the comments, and the disease process/pathophysiology of the patient
- Skill in interpreting and adapting health information guidelines and ability to use judgement in completing assignments using incomplete or inadequate guidelines
6
Skills For Practice Medical Records Coder Westchester Health Medical Resume
- Assigns codes to documented patient care encounters (inpatient and/or outpatient) covering the full range of health care services
- Knowledge of severity of illness and risk of mortality indicators
- Certification - Certification as a Certified Professional Coder at the GS-08 level
- Signed 10-2850c, (Required) "Application for Associated Health Occupations (Revision Jun 2006)
- Applies advanced knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection
7
Skills For Medical Records Technician Coder Clinical Documentation Improvement Specialist Cdis Resume
- Selects and assigns codes from the current version of several coding systems to include current versions of the International Classification of Diseases (ICD), Current Procedural Terminology (CPT), Diagnostic and Statistical Manual of Mental Disorders (DSM), and/or Healthcare Common Procedure Coding System (HCPCS)
- Performs a comprehensive review of the patient health record to abstract medical, surgical, ancillary, demographic, social, and administrative data to ensure complete data capture
- Utilizes the facility computer system and software applications to correctly code, abstract, record, and transmit data to the national VA database in Austin
- Corrects any identified data errors or inconsistencies in a timely manner to ensure acceptance in the national VA database within established timelines. Independently researches references to resolve any questionable code errors
- Identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnosis Related Group (DRG)
- Conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) to determine if based on the documentation the specific coding requirements were followed
- Codes inpatient professional fee services for identified inpatient admissions in support of the Medical Care Cost Recovery (MCCR) program
- Establishes the primary and secondary diagnosis and procedure codes for billable outpatient encounters following applicable regulations, instructions, and requirements for allowable reimbursement; links the appropriate diagnosis to the procedure and/or determines level of Evaluation & Management service provided
- Incumbent develops and conducts seminars, workshops, short courses, information briefings, and conferences concerned with health record documentation, education and functional training requirements to ensure program objectives are met for clinical and Health Information Management Staff
8
Skills For Medical Records Technician Coder Auditor Resume
- Reviews a variety of billing reports including Reasons Not Billable report, denial reports, etc., to ensure Iowa City VA Health Care System is capturing the maximum reimbursement appropriate. Provides feedback to Compliance, providers and service lines regarding documentation requirements for accurate billing
- Works with Quality and Performance Review staff in reviewing and analyzing severity, morbidity and mortality data. Provides feedback regarding coding and documentation requirements
- Assists coding supervisor in providing training to coding staff, providers and service lines
- Facilitates improved overall quality, completeness and accuracy of health record documentation as well as promoting appropriate clinical documentation through extensive interaction with physicians, providers and HIM coding staff to ensure clinical documentation is complete and accurate
- Ensures the accuracy and completeness of clinical information used for measuring and reporting physician and medical center outcomes with continuing education all members of the patient care team on an ongoing basis
- Reviewing documentation regarding conditions that have been adjudicated as a service connection (SC) condition or for special treatment authorities related to exposures or experiences and forwards to Utilization Review as appropriate
- Transcript (if using education to qualify)
- Fill in for the Lead Radiology Coding Lead if needed
- The incumbent assigns codes to documented patient care encounters (inpatient and outpatient) covering the full range of health care services provided by the VAMC
9
Skills For Medical Records Technician Coder Citizens Resume
- The incumbent selects and assigns codes from the current version of several coding systems to include the International Classification of Diseases-Clinical Modification (ICD-10-CM), Diagnostic and Statistical Manual of Mental Disorders (DSM), Current Procedural Terminology (CPT), and HCPCS
- The incumbent adheres to accepted coding practices, guidelines, and conventions when choosing the most appropriate diagnosis, operation, procedure, ancillary, or Evaluation and Management code to ensure ethical, accurate, and complete coding
- The incumbent identifies the principal diagnosis and principal procedure (when applicable) for every inpatient discharge; also identifies significant complications and/or co-morbidities treated or impacting treatment to correctly determine the proper Diagnostic Related Group (DRG)
- The incumbent conducts re-reviews of codes abstracted for patient encounters (inpatient and outpatient) identified by the VISN VERA committee to determine if based on the documentation the specific VERA coding requirements were followed; corrects coding as needed to ensure proper patient classification in the VERA program
- The incumbent codes inpatient professional fee services for identified inpatient admissions in support of the Consolidated Patient Accounts Center (CPAC). Code selection is based upon strict compliance with regulatory fraud and abuse guidelines and VA-specific guidance for optimum allowable reimbursement
- Serves as an expert of current coding conventions and regulations related to professional and facility coding
- Acts as a technical expert in health information coding matters and provides advice and guidance on documentation and coding requirements
10
Skills For Medical Records Technician Coder Clinical Documentation Improvement Specialist Resume
- Performs audits of encounters to identify areas of non-compliance in coding
- Provides recommendations on appropriate coding and is responsible for maintain current knowledge of the various regulatory guidelines and requirements
- Works with staff to ensure regulations are met or areas of weakness are identified and reported to appropriate supervisor for corrective action
- Maintains statistical databases to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management; and
- Performs in depth analysis of electronic medical records to abstract diagnoses and procedures. Ensures charts are received and coded in a timely manner
- Confers with Physicians, residents and billing providers to obtain greater specificity and/or clarification on possible diagnoses and/or procedures performed to ensure accurate coding. Monitors providers on a regular basis for quality of documentation and provides feedback on findings
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