Inpatient Coder

Westchester Medical Center; Town of Mount Pleasant (NY); Presencial; USD 55.000 - 90.000; Jornada completa

Descripción de la vacante

Westchester Medical Center is seeking a Coder to code medical records using ICD for diagnoses and procedures, entering data into an automated grouper system and maintaining accurate DRG determinations.

The role requires 1–2 years of inpatient medical record coding experience, with certification as CCS/CCS-P or CPC preferred and strong knowledge of ICD coding concepts. Proficiency in medical terminology and IT tools is essential.

Formación

• 1–2 years inpatient medical records coding experience.
• Certification CCS/CCS-P or CPC required.
• Thorough knowledge of ICD diagnosis and procedure codes.
• Ability to communicate effectively in English (oral and written).
• Proficient with computer applications and databases.

Responsabilidades

• Code diagnoses and procedures using ICD as documented by physician.
• Ensure accurate DRG by proper ranking of diagnoses.
• Obtain information and clarify as needed.
• Enter final codes and narratives into the grouper system.
• Respond to inquiries about medical documentation and DRGs from hospital staff.

Conocimientos

Medical terminology

Communication

Attention to detail

Educación

High school diploma

Health information management degree (Assoc./Bachelor's)

Herramientas

ICD coding systems

Automated grouper system

Spreadsheets/Word processing/Email/DB software

Descripción del empleo

Job Summary

The Coder is responsible for coding medical records, including all diagnoses and operative and diagnostic procedures in patient medical records, using the current International Classification of Diseases (ICD) for diagnoses and procedures, and entering coded information into an automated grouper system. Does related work as required.

Responsibilities

• Using the current ICD coding systems for diagnoses and procedures, assigns and records an accurate code to all diagnoses, procedures, and operations as documented by the attending physician in the indicated patient's medical record.
• Ensures that all factors necessary for assigning an accurate DRG are present, and that all diagnoses are ranked properly.
• Makes appropriate contacts in order to acquire or clarify necessary information.
• Enters final diagnostic code numbers and narrative descriptions of diagnoses and procedures into an automated grouper system.
• Provides information to and responds to inquiries regarding medical documentation and DRG'S from hospital staff, including utilization and quality assurance staff, patient accounts staff and the Risk Manager.
• Abstracts information from medical records to compile reports and statistical information.
• Enters data such as diagnosis, treatment, admission and discharge dates, length of stay, etc., on hospital-wide or regional automated database.
• Qualifications/Requirements:

Experience

1-2 years of experience where the primary function of the position was inpatient medical records coding in or for a hospital.

Education

High school or equivalency diploma, required. An Associate's degree or Bachelor's degree in health information management may be substituted for one year of the required experience.

Licenses / Certifications

Current certification as either a Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician Based (CCS-P) through AHIMA, or as a Certified Professional Coder (CPC) through the American Academy of Professional Coders.

Other

Thorough knowledge of the current ICD diagnosis and procedure codes; thorough knowledge of medical terminology; thorough knowledge of the principles of the medical record system and its operation; ability to understand and code medical records; ability to communicate effectively both orally and in writing; ability to effectively use computer applications or other automated systems such as spreadsheets, word processing, calendar, e-mail and database software in performing work assignments; ability to read, write, speak, understand, and communicate in English sufficiently to perform the essential duties of the position; thoroughness; sound judgment; tact; discretion; initiative; accuracy; physical condition commensurate with the demands of the position.