Inpatient Coder

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

Job summary

Westchester Medical Center is seeking a skilled Coder to accurately code medical records using ICD guidelines for diagnoses and procedures. You will enter coded data into an automated grouper system and support DRG accuracy in a hospital setting.

The role requires 1–2 years of inpatient medical records coding experience and current certification (CCS/CCS-P or CPC). Strong computer skills and attention to detail are essential to success in this position.

Qualifications

• Requires current certification: CCS, CCS-P, or CPC.
• Thorough knowledge of ICD diagnosis and procedure codes.
• 1–2 years inpatient medical records coding experience required.
• Proficient with computer applications and automated systems.

Responsibilities

• Code diagnoses and procedures using ICD guidelines and input into grouper system.
• Ensure accurate DRG assignment by ranking diagnoses correctly.
• Obtain necessary information from physicians and staff as needed.
• Enter final codes and narratives into the automated grouper system.
• Respond to inquiries about medical documentation and DRGs from hospital staff.
• Abstract information from records to compile reports and statistics.
• Enter data such as admission/discharge dates and length of stay into the system.

Skills

ICD coding knowledge

Medical records coding

Attention to detail

Communication skills

Computer proficiency

Education

High school diploma

Associate's degree in Health Information Management

Bachelor's degree in Health Information Management

Tools

Grouper system software

Electronic health record system

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.
• 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. Special Requirements: