Experienced Inpatient Medical Record Coder
At Stony Brook Medicine, the Coder will be responsible for selecting and assigning accurate codes from the current version of coding systems including ICD-10 CM, ICD-10 PCS, CPT and HCPCS codes. Duties of a Coder may include the following, but are not limited to:
- Demonstrates proficiency with Microsoft Office Applications, Citrix and Adobe Reader in using required computer systems with minimal assistance.
- Reviews the medical record and all applicable documentation to determine the appropriate codes to assign for the services and diagnoses.
- Utilizes coding resources along with any other applicable reference material available to ensure accuracy in coding for all of the assigned services.
- Follows all HIPAA regulations and upholds a higher standard around privacy requirements.
- Demonstrates the technical competence to use the facility encoder as it interfaces with the hospital mainframe and/or EMR in a remote setting.
- Demonstrates proficiency with Microsoft Office Applications in using required computer systems with minimal assistance.
- Maintains a working knowledge of various laws, regulations and industry guidance that impact compliant coding.
- Must meet all coder productivity and quality goals.
- Ensures the confidentiality of data contained in the medical records as outlined in institutional policies and procedures.
- Supports and promotes the HIM department by participating in special projects.
- Assigns and sequences ICD-10CM-PCS diagnostic and procedural codes for designated service lines.
- Working knowledge of MS-DRG and NYS APR DRG grouping logic to accurately reflect the diagnosis, procedures documented in the medical record.
- Documentation assessment and review for accurate abstracting of clinical data to meet regulatory and compliance requirements.
- Other duties as assigned.
Qualifications Required Qualifications:
- Associate's degree, at least 5 years of facility inpatient coding experience and CCS certification OR, in lieu of a degree, At least 8 years of facility inpatient coding experience and CCS certification OR At least 10 years of facility inpatient coding experience
Preferred Qualifications:
- Bachelor's degree in a non-clinical Healthcare related field such as HIM, Health Sciences, Health Informatics or related field
- 10 or more years facility inpatient coding experience
- Experience coding facility inpatient encounters for an academic medical center
Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises. All Hospital positions may be subject to changes in pass days and shifts as necessary. This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair. This function/position may be designated as "essential." This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.
Prior to start date, the selected candidate must meet the following requirements:
- Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services
- Complete electronic reference check with a minimum of three (3) professional references.
- Successfully complete a 4 panel drug screen
- Meet Regulatory Requirements for pre employment screenings.
- Provide a copy of any required New York State license(s)/certificate(s).
Stony Brook University is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws.