Outpatient Coder

Westchester Medical Center Health Network; Town of Warwick (NY); On-site; USD 36,000 - 52,000; Full time

Job summary

Westchester Medical Center Health Network is seeking a qualified Medical Biller/Coder to code medical records using ICD-10-CM, CPT, and HCPCS, and to enter data into a centralized grouper system. The role requires knowledge of documentation and the ability to query clinicians when needed.

The ideal candidate has at least 1 year of outpatient hospital coding experience, a high school diploma or equivalent, and AHIMA or CPC credentials. Strong communication and computer skills are essential.

Qualifications

• High school diploma or GED required; higher degree may substitute for experience.
• Experience coding medical records in a hospital setting preferred (minimum 1 year).
• Current coding certifications (CCS, CCS-P or CPC) required.

Responsibilities

• Code diagnoses and procedures using ICD-10-CM, CPT and HCPCS.
• Enter coded data into automated grouper system.
• Clarify information with providers as needed.
• Query providers to ensure documentation supports coding.
• Generate clinical documentation and coding reports.

Skills

Attention to detail

Medical terminology

Verbal and written communication

Education

High school diploma or GED

Associate's or Bachelor's in health information management substitute for experience

Tools

HCPCS

ICD-10-CM

CPT

CPC/CCS- P

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), Current Procedural Terminology (CPT) and Health Care Financing Administration Common Procedures Coding System (HCPCS) and entering coded information into an automated grouper system. Does related work as required.

Responsibilities

• Using the current HCPCS, ICD 10 CM and CPT coding systems, 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 APC/ APG’s 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.
• Provides information to and responds to inquiries regarding medical documentation, coding, and APCs/APGs from hospital staff, including utilization and quality assurance staff, patient accounts staff and the Risk Manager.
• 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 outpatient 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 as either a Certified Coding Specialist (CCS) or Certified Coding Specialist-Physician Based (CCS-P) through AHIMA, or as a Certified Professional Coder (CPC) through the American Academy of Professional Coders.
Other: Thorough knowledge of the current HCPCS, CPT and ICD 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