Inpatient Coder

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

Job summary

Westchester Medical Center Health Network is seeking an experienced Medical Records Coder to code and abstract inpatient and outpatient accounts. You will coordinate the flow of records between coding staff and analysis staff to ensure accurate data capture.

Responsibilities include reviewing records for ICD-10-CM, ICD-10-PCS, and CPT-4 codes; entering data in U.D.S. and Paragon; and supporting coding audits. This role requires strong attention to detail and communication with physicians.

Qualifications

• 1+ years in Medical Records/HIM or similar health care experience required.
• High School Diploma or Equivalent required; Associate degree preferred.
• Medical Terminology and Coding courses required; advanced terminology and anatomy knowledge preferred.

Responsibilities

• Review records for ICD-10-CM diagnosis codes, identifying principal and secondary diagnoses.
• Review records for ICD-10-PCS procedure codes as applicable.
• Review records for CPT-4 procedure codes as applicable.
• Enter data in U.D.S. and Paragon; assist abstractors and correct errors.
• Evaluate DRG to ensure appropriate coverage of cc where applicable.
• Collaborate with physicians to clarify coding/clinical issues and participate in audits.

Skills

Attention to detail

Professional communication

Data entry accuracy

Education

High School Diploma or Equivalent

Associate's Degree in Medical Records Technology or related

Tools

Paragon system

U.D.S.

Paragon reports

Job description

Job Summary

Codes and abstracts inpatient accounts and outpatient accounts as needed. Assists with abstracting other outpatient accounts and coordinates the flow of medical records between the coding staff and the analysis staff as needed.

Codes and abstracts inpatient accounts and outpatient accounts as needed. Assists with abstracting other outpatient accounts and coordinates the flow of medical records between the coding staff and the analysis staff as needed.

Responsibilities

• Review and evaluate each medical record for appropriate assignment of ICD-10-CM diagnosis code(s). Accurately identifies principle diagnosis and all secondary diagnosis.
• Review and evaluate each medical record for appropriate assignment of ICD-10-PCS procedure code(s), as applicable.
• Review and evaluate each medical record for appropriate assignment of CPT-4 procedure code(s) as applicable.
• Abstract and enter accurately all information in both U.D.S. and Paragon. Assist abstractors in the accuracy of the entries, notify supervisor of any problems with the data entry function. Review inpatient abstracting and correct errors.
• Evaluate selected DRG ensuring appropriate cc are captured if applicable.
• Maintain professional rapport with physicians; contact physicians in questionable cases, suggest inservices, attend inservices given by physicians, ask questions, assist physicians in clarifying coding/clinical issues.
• Participate in coding audits/PI monitors to ensure quality of coding and abstracting. Work with Coding Manager to track/trend the data. Work with the coding team to brainstorm and develop corrective action plans.
• Demonstrate the ability to utilize computer systems for maximum efficiency. Knowledgeable about menus and reports available through Paragon system. Demonstrate ability to utilize all the software programs including U.D.S. and Paragon

Qualifications/Requirements

EXPERIENCE

1 or more years working in a Medical Records/HIM Department, Physician's office, or similar health care experience required.

EDUCATION

High School Diploma or Equivalent required

Associate's Degree in Medical Records Technology, Nursing, or other related field preferred

LICENSES/CERTIFICATIONS

Medical Terminology and Coding courses required

Advanced Medical Terminology and Anatomy/Physiology and knowledge of automated coding/abstracting systems preferred

Certified or working toward one or more of: Certified Coding Specialist (CCS), Certified Coding Specialist – Physician (CCS-P) Certified Professional Coder (CPC), Certified Outpatient Coder (COC) Registered Health Information Technologist (RHIT) or Registered Health Information Administrator (R.H.I.A.).

Other

Working knowledge of computer systems especially PCs and networked environments. Knowledge of alphabetical, numeric, and terminal digit filing systems. Ability to interact with all levels of hospital personnel especially the medical staff. Basic administrative skills (filing, data entry, answering telephone) required.