ON SITE Certified Medical Records Coder - Per Diem - Eastern Long Hospital

Position Summary

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).

• 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.

• 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.

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

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

• Good vision and hearing.
• Operate typewriter or computer keyboard, answer phones, open file drawers.
• Must be able to communicate orally.

The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of SBELIH.

• Stony Brook Medicine is a smoke-free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
• All Hospital positions may be subject to changes in pass days and shifts as necessary.
• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
• This function/position maybe designated as…