Experienced Inpatient Medical Record Coder

Stony Brook University•Commack, NY

About The Position

At Stony Brook Medicine, the Coder will be responsible for selecting and assigning accurate codes from the current version of coding systems including ICD-10 CM, ICD-10 PCS, CPT and HCPCS codes. Duties of a Coder may include the following, but are not limited to: Demonstrates proficiency with Microsoft Office Applications, Citrix and Adobe Reader in using required computer systems with minimal assistance. Reviews the medical record and all applicable documentation to determine the appropriate codes to assign for the services and diagnoses. Utilizes coding resources along with any other applicable reference material available to ensure accuracy in coding for all of the assigned services. Follows all HIPAA regulations and upholds a higher standard around privacy requirements. Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in a remote setting. Demonstrates proficiency with Microsoft Office Applications in using required computer systems with minimal assistance. Maintains a working knowledge of various laws, regulations and industry guidance that impact compliant coding. Must meet all coder productivity and quality goals. Ensures the confidentiality of data contained in the medical records as outlined in institutional policies and procedures. Supports and promotes the HIM department by participating in special projects. Assigns and sequences ICD-10CM-PCS diagnostic and procedural codes for designated service lines. Working knowledge of MS-DRG and NYS APR DRG grouping logic to accurately reflect the diagnosis, procedures documented in the medical record. Documentation assessment and review for accurate abstracting of clinical data to meet regulatory and compliance requirements. Other duties as assigned.

Requirements

Associate’s degree in a non-clinical Healthcare related field such as HIM, Health Sciences, Health Informatics, or related field and at least 5 years of facility inpatient coding experience, OR in lieu of degree, at least 8 years of facility inpatient coding experience.
CCS certification.

Nice To Haves

Bachelor’s degree in a non-clinical Healthcare related field such as HIM, Health Sciences, Health Informatics or related field.
10 or more years facility inpatient coding experience.
Experience coding facility inpatient encounters for an academic medical center.

Responsibilities

Selecting and assigning accurate codes from the current version of coding systems including ICD-10 CM, ICD-10 PCS, CPT and HCPCS codes.
Demonstrates proficiency with Microsoft Office Applications, Citrix and Adobe Reader in using required computer systems with minimal assistance.
Reviews the medical record and all applicable documentation to determine the appropriate codes to assign for the services and diagnoses.
Utilizes coding resources along with any other applicable reference material available to ensure accuracy in coding for all of the assigned services.
Follows all HIPAA regulations and upholds a higher standard around privacy requirements.
Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in a remote setting.
Maintains a working knowledge of various laws, regulations and industry guidance that impact compliant coding.
Must meet all coder productivity and quality goals.
Ensures the confidentiality of data contained in the medical records as outlined in institutional policies and procedures.
Supports and promotes the HIM department by participating in special projects.
Assigns and sequences ICD-10CM-PCS diagnostic and procedural codes for designated service lines.
Working knowledge of MS-DRG and NYS APR DRG grouping logic to accurately reflect the diagnosis, procedures documented in the medical record.
Documentation assessment and review for accurate abstracting of clinical data to meet regulatory and compliance requirements.