Coding Specialist/Transcriptionist

Coding Specialist/Transcriptionist

02 May 2020

Coding Specialist/Transcriptionist

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Our vision is to create safe communities where children are healthy and every family has the opportunity for success. Families get the support they need – when and where they need it. There is a focus on prevention and health; organizations and systems are connected in a synergistic sanctuary community that generates: Non –violence, Growth and Change, Democracy, Emotional intelligence, Social learning, Open communication, and Social Responsibility.


The E/M Coding-Transcription Specialist is responsible for accurate and timely coding of psychiatric outpatient services and querying providers for documentation clarity. To be successful in this position knowledge of E/M coding and utilizing coding rules and regulations, a strong understanding of medical documentation requirements and good communication skills will be necessary. Transcription is responsible for accurate data entry into the electronic medical record. This is a production-based work environment but with quality of work being top priority. Good mastery of spelling, grammar, and punctuation required. Position requires ability to focus in a moderately noisy environment, meet multiple daily deadlines, and can gracefully handle interruptions throughout the work day. Collaborates with HIM Management staff and Billing staff to understand and improve revenue cycle outcomes.


Demonstrates Competency in the Following Areas:

Demonstrates ability to accurately abstract data from provider documentation for accurate CPT/Evaluation and Management code assignment

Demonstrated competency with medical terminology, anatomy and physiology, pharmacology, and pathophysiology

Demonstrates knowledge of ICD, CPT, and HCPCS code sets and guidelines

Demonstrates ability to professionally and effectively communicate with Advanced Practice Clinicians and staff

Demonstrates knowledge of and ability to comply with AHIMA Code of Conduct

Demonstrates ability to effectively prioritize daily workflow

Demonstrates ability to effectively manage time and meet specified deadlines

Demonstrates basic clerical skills with proficiency using computers, software, and various electronic devices

Demonstrates an ability to accurately type and process dictated information

Demonstrates attention to detail

Demonstrates ability to work independently

Demonstrates ability to work collaboratively within a team environment

Demonstrates ability to maintain security and confidentiality of client and other agency records

Demonstrates proficiency in written and spoken English, possess ability to comprehend written instructions and has ability to follow verbal instructions

Professional Requirements:

Accurately code and record psychiatric services as assigned

Maintain departmental coding production and accuracy rates

Review and analyze health assessments to identify unclear or incomplete clinical documentation

Submit queries to providers consistent with established department and agency protocols

Follow-up and report query results per department and agency protocols

Maintains knowledge of CPT/Evaluation and Management Guidelines

Keeps abreast of coding guidelines and reimbursement reporting requirements

Performs self- and inter-rater reliability audits per department protocol

Provides support to the dictation/transcription processes as needed or assigned

Maintains composure under stressful situations

Maintains knowledge of and applies Trillium policies and procedures

Completes all required training in a timely manner

Supports Coding and Clinical Documentation Manager with various duties, as assigned

Complete all job responsibilities in alignment with the core values, mission and vision of the organization

Demonstrated acceptance of a variety of lifestyles, behaviors, and cultures

Other duties as assigned

ADDITIONAL RESPONSIBILITES: Other duties may be assigned.

Supervisory Responsibilities: None

Qualifications Required: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Must be able to pass pre-employment examination.

Education: High School Diploma or equivalent required. Successful completion of college-level medical terminology and anatomy and physiology required. Completion of accredited college-level coding classes required.

Certificates, Licenses, Registrations: Preference given to applicants with recognized certifications in either coding or transcription professional.

Experience: Minimum one year of Evaluation and Management coding or Transcription experience preferred.

Job Knowledge: Operates within established and accepted office procedures and practices. Makes decisions within established guidelines; organizational policy and procedure; federal, state and local laws, rules, and regulations; and the requirements of this job description. Deals with highly sensitive and confidential client information. Work is evaluated based on productivity and accuracy measures as well as feedback from internal customers. The (Coding Specialist) operates independently with minimal supervision. Work is reviewed regularly with direct supervisor.

Skills: Computer skills; knowledge of medical terminology, pharmacology, pathophysiology, and anatomy and physiology; ability to correctly interpret and process written language, good command of grammar and spelling; demonstrated excellent written and oral communication skills; ability to manage and multi-task while exhibiting a sensitivity to internal culture. Must be able to attend to details while not losing sight of the global perspective. Ability to evaluate and assess documentation content from a coding compliance perspective. Ability to communicate and collaborate in conversations with others through phone, email, and face-to-face encounters.

Physical Demands: For physical demands of position, including vision, hearing, repetitive motion and environment, please contact the HR Department. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.

If you need accommodation to review the information and/or complete the application process, please contact the Human Resources Department.

Trillium Family Services is a drug free workplace. All final applicants will be subject to a criminal record identification check pursuant to ORS 181.536.727.537 and agency policy. We are an Equal Opportunity Employer and Service Provider and support a culturally linguistically diverse governance, leadership and workforce.

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