Coder/Abstractor-Outpatient Level II

At White Plains Hospital, you have an opportunity to work side-by-side with some of the most talented people in the world.

We have been widely recognized for our exceptional culture, world-class physicians, Magnet-designated nurses and passionate employees who make a real difference in our community. With tremendous growth opportunities, great benefits, and flexible work schedules, it is no wonder why we are consistently recognized as a Great Place to Work.

Position Summary:

The Outpatient Coder/Abstractor Level II is responsible for coding and abstracting medical records in accordance with established guidelines for outpatient hospital services. This includes, but is not limited to, same-day surgery, observation, emergency department services, clinic services, infusion center services, and diagnostic testing.

Essential Functions and Responsibilities Includes the Following:

1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors.
2. Accurately assign codes to meet established coding guidelines, including ICD-10 CM, CPT-4, HCPCS, and Modifiers.
3. Analyze medical records to identify all appropriate coding and sequencing of diagnoses and procedures.
4. The review of local coverage determinations (LCD)/National Coverage Determination (NCD) alerts is conducted to ensure that diagnoses are accurately captured and documented.
5. Seeks clarification on information needed to assign accurate and specific codes and alerts physician when additional supporting documentation is needed.
6. Limited charge correction and charge validation.
7. Effective communication with other departments is essential.
8. Proficiency in working with spreadsheets is required.
9. The individual must demonstrate the ability to work independently.
10. Query physicians and providers for clarification and documentation improvement when needed.
11. Abstract required data into the health information system, ensuring accuracy in all fields.
12. Meets established quality standards for coding and abstracting medical records.
13. Meets established productivity standards and completes work within required time frames.
14. Stay up to date with industry coding changes, HIM best practices, and payer-specific guidelines.
15. Demonstrates the ability to use Microsoft applications, and HIM software applications including but not limited to 3M 360 coding applications, Optum Lynx.
16. Attend staff meetings as required to update knowledge related to current department/hospital issues/status.
17. Attends educational meetings as requested/required to update knowledge related to coding/compliance.
18. Completes annual department/hospital competency requirements.
19. Performs all other related duties as assigned.

• High School or GED required. Associate's degree preferred.
• Certified Coding Specialist (CCS) and/or Certified Professional Coder (CPC) required if hired as of 1/1/2025
• Minimum of two years of coding experience in a Health Information Management Department preferred.
• Knowledge of ICD-10-CM, HCPCS and CPT-4 coding, medical terminology, anatomy and physiology required.

• Must be detail oriented and accurate.
• Must have a strong understanding of medical terminology, anatomy, and physiology.
• Must be able to work under pressure with time constraints.
• Must be a team player; must be able to retain composure under stress.
• Must interact in a pleasant and professional manner with all internal and external customers and employees.
• Demonstrates the ability to discuss technical issues involving clinical data with Medical Staff and Nursing Staff.
• Must be able to speak, write, and understand the English language; must be able to converse on a clinical level with medical staff to perform required duties.
• Commitment to upholding ethical standards in line with AHIMA Code of Ethics.

• May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital's SDS (Safety Data Sheet) database and may be accessed through the hospital's Intranet site (Employee Tools/SDS Access). A copy of the SDS database can also be found at the hospital switchboard, saved on a disc.
• Must be able to retain focused concentration despite distractions; must be flexible and able to adapt to changes in routines and procedures.
• Ability to remain stationary for extended periods of time (95%).
• Routinely use standard office equipment such as phones, computers, photocopiers, video conference, and fax.
• Trouble shoot computer system and equipment.