Inpatient Coder(Remote)

Westchester Medical Center; City of Kingston (NY); Remote; USD 54,000 - 76,000; Full time

Job summary

Westchester Medical Center is seeking a Medical Records/HIM professional to code inpatient and outpatient records, review for ICD-10-CM/PCS and CPT-4 codes, and ensure accurate DRG capture. The role requires collaboration with physicians and participation in coding audits to uphold data quality.

Qualifications include 1+ year of experience in a Medical Records/HIM setting, an associate degree or better, and familiarity with Paragon and U.D.S. systems; ongoing certifications are preferred.

Qualifications

• 1+ year experience in Medical Records/HIM Department or related healthcare experience.
• Associate's Degree in Medical Records Technology, Nursing, or related field preferred.
• Medical Terminology and Coding courses required; advanced terminology knowledge preferred.

Responsibilities

• Review medical records for appropriate ICD-10-CM diagnosis code(s) and identify principal and secondary diagnoses.
• Review records for ICD-10-PCS procedures and CPT-4 codes as applicable.
• Abstract and enter data in U.D.S. and Paragon; assist and verify data entry accuracy.
• Evaluate DRG to ensure appropriate cc capture when applicable.
• Maintain professional rapport with physicians and clarify coding/clinical issues as needed.
• Participate in coding audits/PI monitors and develop corrective action plans with Coding Manager.

Skills

Automated coding/abstracting systems

Attention to detail

Physician collaboration

Education

Associate's Degree in Medical Records Technology or related field

High School Diploma or Equivalent

Tools

Paragon system

U.D.S.

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. 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.