HealthAlliance Hospital · Medical Records
Location: Kingston, NY
Position Type: Professional/Non-Clinical, Full Time, Day Shift (M-F 8am-4pm)
Job Summary: Responsible for accurate coding of outpatient records, including referred outpatient, ERs, and ASU records, using ICD 10 diagnosis codes and CPT procedure codes. Assists with abstracting when needed.
Responsibilities
- Demonstrate knowledge and accurately assign proper ICD 10 diagnosis codes to all referred outpatient records (e.g., Radiology, Cardiology, Clinics).
- Demonstrate knowledge and accurately assign proper ICD 10 diagnosis and procedure codes and CPT codes to Emergency Department records.
- Demonstrate knowledge and accurately assign proper ICD-10 diagnosis and procedure codes and CPT codes to outpatient procedure records (ASU, Outpatient Medical).
- Review and/or complete Emergency Department charge sheets, assign appropriate Evaluation and Management levels based on documentation, and identify chargeable items.
- Abstract data from coded records into various computer programs as needed.
- Utilize computer systems efficiently, including knowledge of menus and reports available through the Paragon system (Medical Record, Patient Accounting applications) and other software programs.
- Perform other duties as requested to support the coding area.
- Prioritize tasks effectively to maximize productivity.
Qualifications and Requirements
Experience
- Minimum of 2 years working in a Medical Records Department, Physician's Office, or similar healthcare setting.
Education
- Minimum: High School diploma or equivalent.
- Preferred: Associate’s Degree in Medical Records Technology, Nursing, or related field.
Licenses and Certifications
- Required: Minimum of 2 years experience in a Medical Records Department or similar healthcare environment.
Other Requirements
- Working knowledge of computer systems, especially PCs and networked environments.
- Ability to interact effectively with all hospital personnel, including medical staff.
- Basic administrative skills such as filing, data entry, and answering phones.
- Preferred: Ability to prioritize work and meet deadlines.