Experienced Inpatient Medical Record Coder

Stony Brook University•Town of Brookhaven, NY

17d•$77,000 - $101,653

About The Position

At Stony Brook Medicine, the Inpatient Medical Record Coder selects and assigns accurate codes using current coding systems, including ICD-10-CM, ICD-10-PCS, CPT, and HCPCS. The role reviews medical records and supporting documentation, uses coding references and facility systems to ensure accurate coding, and maintains knowledge of laws, regulations, and industry guidance affecting compliant coding. The Coder works with the facility encoder and hospital mainframe and/or electronic medical record, including in a remote setting, and must meet productivity and quality goals. The position includes assigning and sequencing diagnostic and procedural codes for designated service lines, applying knowledge of MS-DRG and NYS APR DRG grouping logic, and reviewing documentation to abstract clinical data accurately for regulatory and compliance requirements. The Coder protects the confidentiality of medical-record data, follows HIPAA and institutional privacy requirements, supports HIM department projects, and performs other duties as assigned. The position may be designated essential during an institutional emergency. It may require respiratory protection, which may prohibit facial hair. Hospital positions may be subject to changes in pass days and shifts as necessary. Before starting, the selected candidate must complete a pre-employment physical and medical clearance, an electronic reference check with at least three professional references, a four-panel drug screen, regulatory pre-employment screenings, and provide copies of any required New York State licenses or certificates.

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.
Must comply with pre-employment requirements, including a physical examination and medical clearance, electronic reference check with at least three professional references, four-panel drug screen, regulatory screenings, and provision of copies of any required New York State licenses or certificates.

Nice To Haves

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

Responsibilities

Select and assign accurate codes using current ICD-10-CM, ICD-10-PCS, CPT, and HCPCS coding systems.
Review medical records and applicable documentation to determine appropriate codes for services and diagnoses.
Use coding resources and other applicable references to ensure coding accuracy.
Use the facility encoder as it interfaces with the hospital mainframe and/or electronic medical record, including in a remote setting.
Maintain working knowledge of laws, regulations, and industry guidance that affect compliant coding.
Meet coder productivity and quality goals.
Ensure confidentiality of medical-record data and follow HIPAA requirements and institutional privacy policies and procedures.
Assign and sequence ICD-10-CM and ICD-10-PCS diagnostic and procedural codes for designated service lines.
Apply working knowledge of MS-DRG and NYS APR DRG grouping logic to accurately reflect diagnoses and procedures documented in the medical record.
Assess and review documentation and abstract clinical data accurately to meet regulatory and compliance requirements.
Support and promote the HIM department by participating in special projects.
Perform other duties as assigned.