Associate Medical Record Specialist

NYC Health + Hospitals; New York (NY); On-site; USD 65,000 - 95,000; Full time

Job summary

NYC Health + Hospitals Jacobi seeks a knowledgeable professional to lead the medical records section, ensure proper coding, and maintain data quality across the department.

The role involves supervising staff, coordinating with other units, and training physicians and nurses on chart documentation. A health information degree and coding credentials are required, with substantial experience in hospital settings.

Qualifications

• Bachelor's degree in Health Information Administration (HIA) or HIT from AHIMA/CAHIIM-accredited program.
• Six months of coding/abstracting experience in a healthcare setting.
• CCS/CPC/CMBS certification plus one year of coding/abstracting experience.

Responsibilities

• Supervises medical record specialists and other staff.
• Plans, assigns and reviews the work of medical records personnel.
• Coordinates work with other units in the department.
• Provides technical advice on record systems and nomenclature.
• Instructs physicians and nurses on chart documentation requirements.
• May code clinical records and analyze records for completeness and accuracy.
• Prepares periodic reports and statistics.
• Coordinates comparative studies by healthcare setting and services.
• Assists in selecting records for medical research and responds to information inquiries.
• Supports data quality initiatives and litigation-related record handling.

Skills

Supervisory experience

Medical coding

Medical records

Education

Bachelor's degree in Health Information Administration or HIT

High school diploma or equivalent

CCS/CPC/CMBS certification

3 years coding/abstracting experience

Job description

Marketing Statement

NYC Health + Hospitals/Jacobi is a 457-bed teaching hospital affiliated with the Albert Einstein College of Medicine. The facility has earned numerous Center of Excellence designations, accreditation, and recognition for its renowned Level 1 Trauma Center, Burn Center, Surgical Intensive Care Unit, regional Stroke Center, Snakebite Treatment Center, Breast Health Center, Bariatric Surgery Center, and Cancer Service. The facility also offers the region’s only multi-person hyperbaric chamber, allowing up to nine patients to dive together at one time. Jacobi’s Ambulatory Care Pavilion is a stunning complement to its inpatient acute care, allowing staff to provide patients with high-quality service in a modern, state-of-the-art environment.

Marketing Statement

NYC Health + Hospitals/Jacobi is a 457-bed teaching hospital affiliated with the Albert Einstein College of Medicine. The facility has earned numerous Center of Excellence designations, accreditation, and recognition for its renowned Level 1 Trauma Center, Burn Center, Surgical Intensive Care Unit, regional Stroke Center, Snakebite Treatment Center, Breast Health Center, Bariatric Surgery Center, and Cancer Service. The facility also offers the region’s only multi-person hyperbaric chamber, allowing up to nine patients to dive together at one time. Jacobi’s Ambulatory Care Pavilion is a stunning complement to its inpatient acute care, allowing staff to provide patients with high-quality service in a modern, state-of-the-art environment.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Duties & Responsibilities

Purpose of Position

Under general supervision, is in charge of a section of the medical record department in a health care setting. Ensures optimal utilization of resources and services and compliance with all applicable local, state, and federal rules and regulations and NYC Health + Hospitals standards of care to improve outcomes through coding and reporting; performs related work.

Essential Duties And Responsibilities

• Supervises medical record specialists and other professional administrative staff.
• Plans, assigns and reviews the work of medical records personnel.
• Coordinates the work of the section of the medical record department with other units of the department and/or health care setting.
• Provides technical advice on record systems and the use of current nomenclature and established indices.
• Coordinates the instruction of physicians, nurses and other health care personnel in chart documentation requirements.
• May code clinical records according to current classification of diseases and operations; may analyze clinical records for completeness and accuracy.
• Prepares periodic reports, statistical abstracts and other records and summaries.
• Coordinates comparative studies by health care setting and services within health care settings and by diseases and operations.
• Assists the medical staff in selecting and collating records for medical research. Answers inquires for information in medical record, in accordance with established policy and legal requirements.
• May perform comparative studies for data quality.
• Analyzes reports to improve medical record data quality and reliability.
• Assists in the performance of functions relating to the filing, retrieval, monitoring, securing and photocopying of medical records identified in litigation proceedings, in accordance with established policies and procedures.

Minimum Qualifications

• Bachelor's degree from an accredited college or university in a health information administration (HIA) or health information technology (HIT) program approved by a nationally accredited agency (e.g., the American Health Information Management Association (AHIMA) or the Commission on Accreditation for Health Informatics and Information Education (CAHIIM)); and six (6) months of experience in coding and/or abstracting medical records in a health care setting; or
• High school diploma or its educational equivalent, approved by a State’s Department of Education or a recognized accrediting organization; and
• Completion of a coding, medical record technology or health information technology (HIT) program approved by a nationally accredited agency (e.g., AHIMA or CAHIIM); and one (1) year of experience in coding and/or abstracting medical records in a health care setting; or
• Certified Coding Specialist (CCS) by AHIMA, Certified Professional Coder (CPC) by the American Academy of Professional Coders (AAPC) or Certified Medical Billing Specialist (CMBS) by the Medical Association of Billers (MAB); and one (1) year of experience in coding and/or abstracting medical records in a health care setting; or
• Three (3) years of satisfactory experience in coding and/or abstracting medical records in a health care setting.

Department Preferences