Hospital Coder

Albany Medical CenterAlbany, NY
Onsite

About The Position

The Hospital Coder applies skills and knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services (including substances, equipment, supplies, or other items used in the provision of healthcare services). This position is responsible for selecting and sequencing the codes such that the organization receives the optimal reimbursement to which the facility is legally entitled, remembering that it is unethical and illegal to increase reimbursement by means that contradict requirements. Use a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD-10-CM/PCS, CPT4, Uniform Hospital Discharge Data Set (UHDDS), Medicare, Medicaid and other fiscal intermediary guidelines. Support the reporting of healthcare data elements (e.g. diagnoses and procedure codes, hospital acquired conditions, patient safety indicators) required for external reporting purposes (e.g. reimbursement, value based purchasing initiatives and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements, as well as all applicable official coding conventions, rules, and guidelines. Query the provider (physician or other qualified healthcare practitioner), whether verbal or written, for clarification and/or additional documentation when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicators). Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. Advances coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. Utilizes official coding rules and guidelines apply the most accurate coding to represent that patient services on the hospital claim. Comply with comprehensive internal coding policies and procedures that are consistent with requirements. Attends coding meetings and roundtable sessions. Participates in daily huddles and LEAN problem-solving activities. Focused with no distractions while working and participating in meetings. Ensures camera on while attending Teams calls. Assists with organizing the shared drive for the medical coding department. Other duties as assigned by manager.

Requirements

  • Skills and knowledge of currently mandated coding and classification systems, and official resources.
  • Ability to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services.
  • Ability to sequence diagnoses and procedures by following the ICD-10-CM/PCS, CPT4, Uniform Hospital Discharge Data Set (UHDDS), Medicare, Medicaid and other fiscal intermediary guidelines.
  • Ability to support the reporting of healthcare data elements required for external reporting purposes.
  • Ability to query the provider for clarification and/or additional documentation.
  • Commitment to continuing education.
  • Demonstrates behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.
  • Ability to utilize official coding rules and guidelines.
  • Ability to comply with comprehensive internal coding policies and procedures.
  • Ability to focus with no distractions while working and participating in meetings.
  • HIPAA Protected Health Information and other information regulated by Federal and New York State statutes awareness.

Nice To Haves

  • Access to information considered sensitive to Albany Med Health System, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes.

Responsibilities

  • Applies skills and knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services.
  • Uses a computerized encoding system to facilitate accurate coding.
  • Sequences diagnoses and procedures by following the ICD-10-CM/PCS, CPT4, Uniform Hospital Discharge Data Set (UHDDS), Medicare, Medicaid and other fiscal intermediary guidelines.
  • Supports the reporting of healthcare data elements required for external reporting purposes.
  • Queries the provider (physician or other qualified healthcare practitioner), whether verbal or written, for clarification and/or additional documentation when there is conflicting, incomplete, or ambiguous information in the health record.
  • Advances coding knowledge and practice through continuing education.
  • Demonstrates behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.
  • Utilizes official coding rules and guidelines to apply the most accurate coding to represent patient services on the hospital claim.
  • Complies with comprehensive internal coding policies and procedures that are consistent with requirements.
  • Attends coding meetings and roundtable sessions.
  • Participates in daily huddles and LEAN problem-solving activities.
  • Ensures camera on while attending Teams calls.
  • Assists with organizing the shared drive for the medical coding department.
  • Performs other duties as assigned by manager.

Benefits

  • Excellent health care coverage with no copay at Albany Medical Center providers
  • A wide array of services and programs to support emotional, physical, and mental wellbeing
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