Coder

Northwell Health; Village of Lake Success (NY); On-site; USD 55,000 - 86,000; Full time

Job summary

Northwell Health in Lake Success, NY is seeking a Medical Coder/Abstractor to perform coding and abstracting for patient records in accordance with UHDDS, CPT, and CMS guidelines.

Responsibilities include analyzing medical records, assigning diagnoses and procedures, coordinating with physicians for clarifications, and ensuring timely and accurate data for facility reimbursement. Requires CPC/CCS/RHIT or equivalent certification and 1–3 years of coding experience.

Qualifications

• High School Diploma or equivalent required.
• 1-3 years of technical coding experience required.
• Preferred - 1-3 years of inpatient, outpatient, professional coding experience
• Must have CPC, CCS or RHIT certification

Responsibilities

• Analyzes and interprets the medical record to ensure accurate diagnoses and procedures for proper facility payment.
• Applies anatomy and physiology knowledge to interpret documentation and identify codes.
• Uses reference materials to identify appropriate codes and guidelines.
• Applies UHDDS definitions and CMS rules for principal/secondary diagnoses and procedures.
• Assigns discharge dispositions and reports POA indicators as required.
• Generates physician queries to clarify documentation and ensures final coding determinations.

Skills

Technical experience

CPC

CCS

RHIT

Education

High School Diploma or equivalent

CPC

CCS

RHIT

Job description

• Job Category Health Information Management
• Posting Date 07/31/2026, 07:02 PM
• Locations 1111 Marcus Ave, Lake Success, NY, 11042, US
• Job Schedule Full time
• Minimum Salary/Range* 55,070.0000
• Maximum Salary/Range* 85,720.0000
• Shift Days
• Shift Begin Time 8:00 AM
• Shift End Time 4:00 PM
• Schedule Full Time
• Requisition Primary Location Lake Success, NY, United States

Job Description

Job Description

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records.

Job Responsibility

• Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment.
• Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes.
• Utilizes resources and reference materials (e.g., on-line sources, manuals) to identify appropriate codes and reference code applicability, rules and guidelines.
• Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/ or coding references to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient's acuity, severity of illness and risk of mortality (if applicable), as documented in the medical record.
• Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures.
  Accurately assigns discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations.
  Make determinations on medical coding and takes initiative to complete reviews and coding independently, to avoid delays in the workflow process
• Manages multiple work demands simultaneously to maintain relevant efficiency and turnaround time standards for completing coding/DRG assignment.
• Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection, Congenital Malformations and Expirations.
• For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets.
• Assigns appropriate discharge physician in the system.
• Generates compliant physician queries to clarify any incomplete/ambiguous or conflicting documentation and applies post-query responses to make final coding determinations.
• Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines and regulations.
• Completes standardized tasks that are guided by policies, procedures, guidelines and precedents to provide ongoing function support.
• Makes routine and few non-routine decisions with some latitude, but still subject to approval.
• Ensures timely and accurate performance of responsibilities; produces quality results with work frequently reviewed.
• Elevates questions, problems and significant challenges to more senior team members for direction or subject matter expertise on new or unprecedented assignments.
• Performs related duties, as required.

*ADA Essential Functions

Job Qualifications:

• High School Diploma or equivalent required.
• 1-3 years of technical experience, required.

Preferred Qualifications:

• Preferred - 1-3 years of inpatient, outpatient, professionalcoding experience
• Must haveCPC, CCS orRHIT certification

*Additional Salary Detail
The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

It is Northwell Health’s policy to provide equal employment opportunity and treat all applicants and employees equally regardless of their age, race, creed/religion, color, national origin, immigration status or citizenship status, sexual orientation, military or veteran status, sex/gender, gender identity, gender expression, disability, pregnancy, genetic information or genetic predisposition or carrier status, marital or familial status, partnership status, victim of domestic violence, sexual or other reproductive health decisions, or other characteristics protected by applicable law.

Northwell Health reserves the right to amend all terms of employment.