Inpatient Coder

Westchester Medical Center Health Network; Town of Mount Pleasant (NY); On-site; USD 65,000 - 90,000; Full time

Job summary

Westchester Medical Center Health Network seeks a skilled Coder to code medical records, diagnoses, and procedures using ICD standards. You will ensure accurate DRG assignments and enter data into centralized grouper systems, while supporting QA and utilization teams.

Ideal candidates have 1–2 years inpatient coding experience, strong medical terminology knowledge, and full proficiency with EMR and related software. Certification in CCS/CCS-P or CPC is preferred.

Qualifications

• 1–2 years of inpatient medical records coding experience.
• High school diploma or equivalent; Associate/Bachelor in health information management may substitute for one year of experience.
• Current CCS/CCS-P or CPC certification preferred.
• Thorough knowledge of ICD diagnosis and procedure codes; medical terminology; medical records system.

Responsibilities

• Code all diagnoses and procedures using ICD coding; ensure accurate DRG designation.
• Enter coded data and narrative descriptions into the grouper system.
• Abstract information from medical records to compile reports and statistics.
• Respond to inquiries from hospital staff regarding medical documentation and DRGs.
• Communicate effectively in writing and orally; use computer applications for data entry and report generation.

Skills

ICD coding

Medical terminology

Medical records coding

Communication skills

Computer systems

Education

High school diploma

Health Information Management degree

Tools

Automated grouper systems

EMR systems

Job description

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.

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.