Inpatient Coder(Remote)

MedicalVirtual; Village of Margaretville (NY); Remote; USD 42,000 - 64,000; Full time

Job summary

MedicalVirtual in Margaretville, NY is seeking a Medical Records Abstractor to review inpatient and outpatient records for ICD-10-CM diagnoses and ICD-10-PCS/CPT-4 procedures as applicable. The role involves accurate data entry into U.D.S.

and Paragon, collaboration with physicians, and participation in coding audits to ensure quality. Requirements include 1+ year in a Medical Records/HIM setting, High School diploma, and coursework or certification in medical terminology and coding; an

Qualifications

• Knowledge of ICD-10-CM/PCS coding principles and outpatient/inpatient coding.
• Experience with medical record abstracting and charge capture.
• Familiarity with coding audits and PI monitors.

Responsibilities

• Review medical records for accurate ICD-10-CM diagnosis coding.
• Identify principal and secondary diagnoses with accuracy.
• Code ICD-10-PCS procedures and CPT-4 procedures when applicable.
• Abstract data into U.D.S. and Paragon systems accurately.
• Assist abstractors and notify supervisor of data entry issues.
• Support coding audits and trend data with the Coding Manager.
• Maintain professional rapport with physicians to clarify coding questions.

Skills

Medical terminology

Coding knowledge

Attention to detail

Data entry

Education

High School Diploma or Equivalent

Associate’s Degree in Medical Records Technology or related field

Tools

Paragon system

U.D.S.

Job description

Margaretville, New York, 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.

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