Certified Medical Records Coder- PD

Stony Brook University•Greenport, NY

About The Position

In this role, the successful candidate analyzes medical records, extracts clinical, pathological, therapeutic and epidemiologic data for Inpatient and/or Outpatient records in accordance with established ICD-10-CM/PCS and CPT coding principles and guidelines. Health Information Coders analyze, abstract, and code in order for the hospital to submit a bill for services rendered and various departments and clinics associated with patient care; perform other related duties as required. Medical coding is a critical aspect of HIM. Professionals assign standardized codes to diagnoses and procedures, which are used for billing, insurance claims, and statistical analysis. They use coding systems such as ICD-10 (International Classification of Diseases) and CPT (Current Procedural Terminology).

Requirements

Coding Certification (ie. CCS, CCA, CPC).
Knowledge of electronic medical records and 3M or Encoder System.
Strong knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process.
Knowledge of MS DRG prospective payment system and severity systems.
Ability to concentrate for extended periods of time.
Ability to work and make decisions independently.

Nice To Haves

Electronic Medical Record system experience.
Hospital-based coding experience.

Responsibilities

Abstracts and codes medical information from Inpatient and/or Outpatient charts into the organization billing/abstracting systems to complete the coding function through established best practice processes and professional regulatory coding guidelines, policies and procedures.
Ensures that each diagnosis present on admission (POA) indicator is assigned appropriately.
Adheres to coding compliance policies and procedures for assignment of complete, accurate, timely and consistent codes.
Identify and request physician queries following established guidelines when existing documentation is unclear or ambiguous following appropriate standards and guidelines and established organization.
Ensures all open queries have been addressed, collaborating with Clinical Documentation Specialist when necessary, prior to final coding.
Adheres to department standards for productivity and accuracy.
Identifies and trends coding issues and escalating identified concerns to Department Director.
Participates in on site, remote and/or external training workshops and training. Demonstrates proficiency in utilizing official coding books as well as the electronic medical record.
Consults, provides professional expertise to and collaborates with clinical documentation specialists on coding and documentation practices and standards.
Maintains active and up-to-date coding certification by meeting continuing education requirements.
Performs other duties as assigned.