Experienced Inpatient Medical Record Coder

Stony Brook University•Town of Brookhaven, NY

40d•Remote

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. This role involves reviewing medical records and documentation to determine appropriate codes for services and diagnoses, utilizing coding resources and reference materials for accuracy, and adhering to HIPAA regulations and privacy requirements. The Coder will demonstrate technical competence in using the facility encoder, its interface with the hospital mainframe and/or EMR in a remote setting, and maintain a working knowledge of laws, regulations, and industry guidance impacting compliant coding. Additionally, the position requires meeting coder productivity and quality goals, ensuring data confidentiality, and supporting the HIM department through special projects. The Coder will assign and sequence ICD-10CM-PCS diagnostic and procedural codes for designated service lines, with a working knowledge of MS-DRG and NYS APR DRG grouping logic. This includes documentation assessment and review for accurate abstracting of clinical data to meet regulatory and compliance requirements. Other duties as assigned.

Requirements

Associate’s degree, at least 5 years of facility inpatient coding experience and CCS certification OR, in lieu of a degree, at least 8 years of facility inpatient coding experience and CCS certification OR at least 10 years of facility inpatient coding experience.
Proficiency with Microsoft Office Applications, Citrix and Adobe Reader in using required computer systems with minimal assistance.
Proficiency with Microsoft Office Applications in using required computer systems with minimal assistance.
Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services.
Complete electronic reference check with a minimum of three (3) professional references.
Successfully complete a 4 panel drug screen.
Meet Regulatory Requirements for pre employment screenings.
Provide a copy of any required New York State license(s)/certificate(s).

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

Selects and assigns accurate codes from current versions of coding systems including ICD-10 CM, ICD-10 PCS, CPT and HCPCS codes.
Reviews medical records and all applicable documentation to determine the appropriate codes to assign for services and diagnoses.
Utilizes coding resources and other applicable reference material to ensure accuracy in coding for all assigned services.
Follows all HIPAA regulations and upholds a higher standard around privacy requirements.
Demonstrates 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.
Meets 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.
Applies working knowledge of MS-DRG and NYS APR DRG grouping logic to accurately reflect the diagnosis and procedures documented in the medical record.
Performs documentation assessment and review for accurate abstracting of clinical data to meet regulatory and compliance requirements.
Performs other duties as assigned.