Inpatient Coder

Westchester Medical Center Health Network; Town of Warwick (NY); On-site; USD 60,000 - 75,000; Full time

Job summary

Westchester Medical Center Health Network seeks a Hospital Coder to assign and record ICD-10 CM/PCS codes for diagnoses and procedures in patient records and enter coded data into the automated grouper system.

Requires at least one year of inpatient medical records coding experience, a high school diploma (an associate or bachelor in health information management may substitute for experience) and CCS certification; strong knowledge of medical terminology is essential.

Qualifications

• One year inpatient medical records coding experience.
• Current CCS certification is required.
• Thorough knowledge of ICD-10CM/PCS codes and medical terminology.
• Ability to use computer applications and automated coding systems.

Responsibilities

• Code diagnoses and procedures accurately using ICD-10 CM/PCS.
• Ensure DRG factors and diagnoses are ranked correctly.
• Contact providers to clarify documentation as needed.
• Enter codes and narrative descriptions into the automated grouper.
• Abstract data from records to compile reports and statistics.
• Enter admission/discharge dates and length of stay into databases.
• Query providers regarding documentation when needed.

Skills

Verbal & written communication

Attention to detail

Medical terminology

Anatomy & physiology

Computer literacy

Education

High school diploma or equivalent

Associate's or Bachelor's in health information management (substitution for experience)

Tools

ICD-10 CM/PCS coding systems

Automated grouper system

Microsoft Office/IT systems

Job description

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 10 CM/PCS) for diagnoses and procedures, and entering coded information into an automated grouper system. Does related work as required.

Responsibilities

• Using the current ICD10 CM/PCS 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.
• 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.
• Query appropriate provider as necessary regarding documentation of diagnosis and/or procedure.

Qualifications/Requirements

Experience

Minimum of one year 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 is Certified Coding Specialist (CCS) required.

Other

Thorough knowledge of the current ICD10CM/PCS diagnosis and procedure codes; thorough knowledge of medical terminology, anatomy and physiology; ability to understand and code medical records; ability to communicate effectively both verbally and in writing; ability to effectively use computer applications or other automated systems such as spreadsheets, word processing, calendar and e-mail for performing work assignments; ability to read, write, speak, understand, and communicate sufficiently to perform the essential duties of the position.

Special Requirements

N/A