Senior Coder (IP/ASU)

Northwell Health; Village of Lake Success (NY); Remote; USD 50,000 - 80,000; Full time

Job summary

Join a forward-thinking healthcare organization where you will play a vital role in ensuring accurate coding and documentation practices. This position involves analyzing medical records, applying coding guidelines, and collaborating with healthcare professionals to enhance coding accuracy. You will have the opportunity to work independently while managing multiple demands in a dynamic environment. With a focus on continuous education and improvement, this role offers a chance to make a significant impact on the quality of healthcare data and facility payments. If you are detail-oriented and passionate about coding, this is the perfect opportunity for you.

Qualifications

• 3-5 years of technical experience in medical coding required.
• Certification such as CCS, CPC, or RHIT is mandatory.

Responsibilities

• Analyzes medical records for accurate coding of diagnoses and procedures.
• Collaborates with leads to resolve technical challenges in coding.

Skills

Medical Coding

Anatomy and Physiology Knowledge

Attention to Detail

Documentation Practices

Education

High School Diploma or equivalent

Certification (CCS, CPC, etc.)

Tools

Coding Guidelines (OCG, AHA Coding Clinic)

SPARCS

Job description

Remote Work Schedule: Sun-Thurs or Tues-Sat flexible hours between 7am-7pm

Job Description

Performs coding and abstracting duties to ensure accurate completion of coding for all assigned patient records.

Job Responsibilities

1. Analyzes and interprets the medical record in its entirety to ensure accurate, complete, and consistent selection of diagnoses and procedures, thereby ensuring the production of quality healthcare data and accurate facility payment.
2. Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes.
3. Utilizes resources and reference materials (e.g., manuals, online resources: Official Coding Guidelines (OCG), AHA Coding Clinic, CMS, CPT Assistant) to identify appropriate codes and reference code applicability, rules, and guidelines.
4. Applies UHDDS definitions and other regulatory guidelines to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating patient acuity, severity of illness, and mortality risk, as documented in the medical record.
5. Codes and reports diagnoses and their associated POA indicators and procedures.
6. Accurately assigns discharge disposition in accordance with CMS rules and regulations.
7. Makes independent determinations on medical coding to avoid workflow delays.
8. Manages multiple work demands to maintain efficiency and turnaround time standards for coding and DRG assignment.
9. Reports data elements for systems like SPARCS, including congenital malformations and expirations.
10. For outpatient encounters, applies coding conventions and guidelines established by CPT and other official rules for outpatient procedures.
11. Assigns appropriate discharge physician in the system.
12. Generates compliant physician queries to clarify documentation and applies responses for final coding.
13. Demonstrates basic knowledge of how coding decisions impact revenue cycle.
14. Assists in educating physicians and clinicians on documentation practices to improve coding accuracy.
15. Participates in hospital education programs to stay updated on coding changes.
16. Completes moderately complex assignments, recognizing when to deviate from standard practices.
17. Exercises independent judgment on job-related issues.
18. Works independently under minimal supervision within established guidelines.
19. Collaborates with leads on technical or procedural challenges.
20. May guide team members to ensure accuracy and timeliness.
21. Performs related duties as required.

Job Qualifications

• High School Diploma or equivalent required.
• 3-5 years of technical experience required.
• Certification such as CCS, CPC, CCSP, CIC, COC, RHIA, or RHIT required.

Additional Salary Details

The salary range listed is a good faith estimate and may be adjusted based on factors like location, experience, education, credentials, and internal policies.