職位描述
Department OverviewUnited Family Hospitals & Clinics is a pioneering, international standard healthcare organization in China, our sole mission is to provide comprehensive, integrated healthcare services in a uniquely warm and caring patient and family service-oriented environment.Job DescriptionResponsible for patient information release issues, accuracy and completeness of coding and abstracting of diagnoses and procedures, and accurate and prompt transcription of dictated medical reports. Also assists medical record supervisor in the efficient and effective management of Medical Record Department consistent with the medical, administrative, ethical and legal requirements of the health care delivery system. Substitutes for other medical record department staffs as needed.Responsibilities1. Taking request from patients, verifying the patient or the request or identification, photocopying the medical records, faxing or mailing medical records as request, etc.2. Review patient records for accuracy and completeness for the disease and procedural information, comparing documented pathology and consulting diagnosis with the discharge diagnosis.3. Utilize the International Classification of Diseases-10th Edition-Clinical Modification, Volumes1-3 to derive accurate and complete ICD-10-CM codes for all diagnoses and procedures.4. Enter the ICD-10-CM codes for diagnoses and procedures on the face sheet, sequencing the principal diagnosis and the principal procedure.5. Transfer demographic and medical information from each discharge medical record into the computer abstract program in a timely and accurate manner.6. Re-analyze charts for any remaining incomplete items.7. Collect and analyze patient and institutional data for health care and health related programs.8. Transcribe medical report upon requested.9. Substitute for other medical record department staffs as needed.Requirements1. University level or equivalent majored in medical record or health information management preferred2. One-year coding and medical record management experience preferred. On the job training can be provided to those who meet the educational specifications.3. Must have ability to speak, understand and be understood in the English language.4. Requires judgment in applying broad aspects of established coding practices to situations that do not exactly conform to accept precedents.5. Works toward assigned objectives of accuracy and completeness of coding, sequencing and transcription6. Must have a working knowledge of medical terminology, anatomy, physiology and disease processes.
