Outpatient Coding Specialist

Downstate; New York (NY); On-site; USD 52,000 - 76,000; Full time

Job summary

SUNY Downstate Health Sciences University seeks a full-time TH Medical Records Specialist / Outpatient Coding Specialist to review and code outpatient records, ensuring accurate documentation and compliant billing. This role collaborates with physicians and Health Information Management staff to maintain coding integrity.

The position requires knowledge of medical terminology, coding methodologies, and reimbursement guidelines, with a focus on completeness, accuracy, and timely revenue cycle

Qualifications

• Knowledge of medical terminology, clinical documentation, and outpatient coding methodologies.
• Understanding of healthcare reimbursement guidelines and coding conventions.
• Ability to query physicians and collaborate with health information management staff to ensure coding accuracy.

Responsibilities

• Review outpatient records to abstract information and assign ICD-10-CM, CPT, and HCPCS Level II codes.
• Assign accurate diagnosis and procedure codes based on documentation and guidelines.
• Ensure coding compliance with official guidelines, payer requirements, and regulations.
• Review documentation for completeness and accuracy to support proper reimbursement.
• Identify unclear documentation and initiate physician queries for clarification.
• Maintain knowledge of coding systems and regulatory updates.

Skills

Medical terminology

Clinical documentation

Outpatient coding

HIPAA compliance

Tools

EHR systems

Coding software

Job description

The Department of Health Information Management at SUNY Downstate Health Sciences University is seeking a full-time TH Medical Records Specialist / Outpatient Coding Specialist.

Job Summary

The Outpatient Coding Specialist is responsible for reviewing, analyzing, and accurately coding outpatient medical records in accordance with established coding guidelines, regulatory requirements, and institutional policies. The incumbent abstracts relevant clinical information and assigns appropriate diagnosis and procedure codes to ensure accurate documentation, coding compliance, and appropriate reimbursement for outpatient services.

The position requires knowledge of medical terminology, clinical documentation, outpatient coding methodologies, and applicable healthcare reimbursement guidelines. The Outpatient Coding Specialist works collaboratively with physicians, clinical departments, and Health Information Management staff to resolve documentation deficiencies, maintain coding accuracy, and support the integrity of the institution's health information and revenue cycle processes.

Key Responsibilities & Duties

• Review and analyze outpatient medical records to accurately abstract clinical information and assign appropriate ICD-10-CM, CPT, and applicable HCPCS Level II codes in accordance with established coding guidelines.
• Assign accurate and complete diagnosis and procedure codes based on physician documentation, clinical findings, and applicable outpatient coding conventions.
• Ensure coding accuracy, consistency, and compliance with official coding guidelines, payer requirements, institutional policies, and applicable federal and state regulations.
• Review clinical documentation for completeness, specificity, and accuracy to support appropriate code assignment and reimbursement.
• Identify incomplete, conflicting, or unclear documentation and initiate appropriate physician queries to obtain clarification in accordance with established documentation integrity and compliance standards.
• Apply outpatient coding guidelines, including appropriate sequencing of diagnoses and procedures, medical necessity requirements, and applicable coding edits.
• Maintain current knowledge of coding classification systems, regulatory updates, reimbursement methodologies, and changes to coding guidelines.
• Support accurate and timely coding of outpatient encounters to facilitate efficient billing, claims processing, and revenue cycle operations.
• Identify coding discrepancies, documentation deficiencies, and potential compliance concerns and communicate findings to the Coding Manager or appropriate departmental leadership.
• Collaborate with physicians, clinical staff, Health Information Management personnel, and other hospital departments to resolve coding and documentation issues.
• Utilize electronic health records, coding applications, and other health information systems to review documentation, assign codes, and maintain accurate coding records.
• Maintain established departmental standards for coding accuracy, productivity, turnaround times, and quality.
• Ensure the confidentiality, security, and integrity of patient health information in accordance with HIPAA regulations and institutional policies.
• Participate in coding audits, quality assurance activities, staff education, and process improvement initiatives, as assigned.
• Perform other job-related duties as assigned and/or required.