Coding Specialist

Maimonides Medical Center Inc.; New York, Northern (NY, KY); Hybrid; USD 113.728.000 - 147.403.000; Vollzeit

Zusammenfassung

Maimonides Medical Center Inc. is seeking a Medical Records Coder to review and code inpatient and outpatient records using ICD-10-CM/PCS, CPT-4, and AHIMA/AAPC guidelines. You will abstract data for DRGs and ensure accurate, compliant coding across diverse cases.

The role requires high attention to detail, strong terminology knowledge, and the ability to communicate with physicians for clarification. Prior coding experience and testing are essential.

Qualifikationen

• High School graduation or equivalent required.
• AHIMA/AAPC coding certifications; CCS/CCS-P or RHIT/RHIA preferred.
• 1 year coding experience preferred; knowledge of ICD-10-CM/PCS, CPT-4.
• Knowledge of APCs and APGs; passes coding and data-entry tests; English proficient.

Aufgaben

• Assigns and sequences ICD-10-CM/PCS codes for all cases.
• Abstracts data for DRG determination and regulatory reporting.
• Reviews records for accuracy and enters data into the hospital system.
• Ensures quality control and supports chart coding integrity daily.
• Identifies discrepancies and communicates with physicians for clarification.
• Participates in department quality improvement and training.

Kenntnisse

Medical terminology

AHIMA coding

Attention to detail

Communication skills

Ausbildung

AHIMA CCS

AAPC CPC

RHIT / RHIA preferred

Tools

Encoder

Jobbeschreibung

About Us

We’re Maimonides Health, Brooklyn’s largest healthcare system, serving over 250,000 patients each year through the system’s 3 hospitals, 1800 physicians and healthcare professionals, more than 80 community-based practices and outpatient centers. At Maimonides Health, our core values H.E.A.R.T drives everything we do. We uphold and maintain Honesty, Empathy, Accountability, Respect, and Teamwork to empower our talented team, engage our respective communities and adhere to Planetree's philosophy of patient-centered care. The system is anchored by Maimonides Medical Center, one of the nation’s largest independent teaching hospitals and home to centers of excellence in numerous specialties; Maimonides Midwood Community Hospital (formerly New York Community Hospital), a 130-bed adult medical-surgical hospital; and Maimonides Children's Hospital, Brooklyn's only children's hospital and only pediatric trauma center. Maimonides' clinical programs rank among the best in the country for patient outcomes, including its Heart and Vascular Institute, Neuroscience Institute, Boneand Joint Center, and Cancer Center. Maimonides is an affiliate of Northwell Health and a major clinical training site for SUNY Downstate College of Medicine.

Overview

Data management functions in a variety of application areas; including clinical coding, outcomes

management, and specialty registries. Reviews medical records to confirm diagnoses and apply appropriate

disease and procedure codes in ICD-10- CM, ICD-10-PCS and CPT-4 classification systems.

Abstracts and analyses records for appropriateness of documentation for assigning DRG. Enters data into computer system to produce documentation required for correct patient billing. Assists in protecting legal interests of the patient, hospital and physician. Data Entry, and retrieval of data for the purpose of statistical reporting.

Responsibilities

• Examines the medical record for consistency and accuracy of identifying information; reports any discrepancies or problems to supervisor
• Reviews medical record to determine all diagnoses and procedures in order to assign the appropriate codes.
• Assigns and sequences ICD-10-CM diagnostic and ICD-10-PCS procedural coding on all cases and utilizes AHIMA coding guidelines
• Abstracts data required by federal and state regulatory agencies (e.g., physician information, patient demographics) and enters into hospital computer system
• Analyzes for optimization and DRG assignments utilizing Encoder
• Identifies documentation specifics to support the diagnoses; provides the supervisor with the information to be communicated to the physicians
• Carries out all quality control procedures required by the department to ensure the accuracy of data
• Meets the required daily coding (ICD-10) and competency levels established for inpatient medical records (14-16) records with error rate <5%)
• Meets required coding (ICD-10) and competency standards for Ambulatory Surgical records. (30-35) amb/sur records with error rate <8%)
• Meets the required daily coding (ICD-10) and competency levels established for inpatient medical records (14 records with error rate <5%). Amb/surg records with error rate <8%.
• Inserts tumor registry forms in record when required
• Competes DOH forms for appropriate records, i.e. Alzheimer’s and CMRResponsible for submitting DOH forms to the responsible person in a timely manner
• Assigns charts to appropriate review area for quality check
• Participates in the quality improvement process of the department and/or medical center
• Participates in the educational programs and in-service meetings to enhance skills and development as demonstrated by record of in-service/continuing education
• Maintains and enhances professional growth and development through educational programs, workshops, and professional affiliations
• Maintains established departmental pollicies and procedures, objectives, compliance program, confidentiality, safety, environmental, and infection control standards
• Assists in selecting, training, assigning, and monitoring staff; evaluates performance; and makes recommendations for personnel action

Qualifications

High School graduation or equivalent required.

Successful completion of a coding certificate program in ICD-10-CM, ICD-10-PCS, CPT-4 coding recognized by the American Health Information Management Association (AHIMA) and/or American Association of Professional Coders (AAPC) required. CCS, CCS-P, RHIT, or RHIA preferred.

1-year prior coding experience preferred. Knowledge of medical terminology, disease processes, pharmacology, anatomy, physiology required; Knowledge of E&M, CPT, ICD-10, and HCPCS coding required; Knowledge of APCs and APGs required; Must pass basic coding test; Must pass basic data entry skills test; Good oral and written communication skills; Good interpersonal skills; Speaks, reads, and writes English to the extent required by the position; knowledge of a second language preferred.

Pay Range

USD $39.69 - USD $51.45 /Hr.

Equal Employment Opportunity Employer

Maimonides Medical Center (MMC) is an equal opportunity employer.