Inpatient Coder(Remote)

Maria Fareri Children's Hospital, a member of the WMCHealth Network; Village of Margaretville (NY); Remote; USD 55,000 - 82,000; Full time

Job summary

Maria Fareri Children's Hospital is seeking a Medical Records Technician to code inpatient and outpatient accounts, abstract records, and coordinate data flow between coding and analysis teams.

This role requires 1+ year in Medical Records/HIM, a high school diploma or equivalent, and preferred an Associate's degree. Certification in medical terminology and coding is required or in progress; multiple coding credentials are valued. Proficiency with Paragon and UDS is expected.

Qualifications

• Experience: 1+ years in Medical Records/HIM department or similar health care setting.
• Education: High School Diploma or Equivalent.
• Associate's Degree in Medical Records Technology, Nursing, or related field preferred.
• Licenses/Certifications: Medical Terminology and Coding courses required.
• Preferred certifications: CCS, CCS-P, CPC, COC, RHIT, or RHIA.
• Other: Working knowledge of computer systems; ability to interact with hospital personnel; basic data entry skills.

Responsibilities

• Code inpatient and outpatient accounts using ICD-10-CM, ICD-10-PCS, and CPT-4 as applicable.
• Abstract and enter information in U.D.S. and Paragon; assist with data accuracy; review inpatient abstracts.
• Identify principal and secondary diagnoses and ensure correct DRG where applicable.
• Maintain professional rapport with physicians; discuss questionable cases; participate in inservices.
• Participate in coding audits/PI monitors; collaborate with Coding Manager on data trends and corrective actions.
• Utilize Paragon and U.D.S. systems and related software for efficient coding and abstracting.

Skills

Medical Records/HIM experience

Medical terminology knowledge

Coding knowledge

Data entry proficiency

Professional communication

Administrative skills

Education

High School Diploma or Equivalent

Associate's Degree in Medical Records Technology or related field

Tools

Paragon system

U.D.S.

Job description

Job Title

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.