Certified Medical Records Coder - Per Diem - Eastern Long Island 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).

Job Duties & Essential Functions:

• 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.