Certified Medical Records Coder - On Site - Eastern Long Island Hospital

About the role

The selected candidate will work on site in Greenport, NY for all shifts.

Job Duties & Essential Functions

• Abstracts and codes medical information from Inpatient and/or Outpatient charts into the organization billing/abstracting systems to complete the coding function through established best practice processes and professional regulatory coding guidelines, policies and procedures.
• Ensures that each diagnosis present on admission (POA) indicator is assigned appropriately.
• Adheres to coding compliance policies and procedures for assignment of complete, accurate, timely and consistent codes.
• Identify and request physician queries following established guidelines when existing documentation is unclear or ambiguous following appropriate standards and guidelines and established organization.
• Safeguards all open queries have been addressed, collaborating with Clinical Documentation Specialist when necessary, prior to final coding.
• Adheres to department standards for productivity and accuracy.
• Identifies and trends coding issues and escalating identified concerns to Department Director.
• Participates in on site, remote and/or external training workshops and training.
• Demonstrates proficiency in utilizing official coding books as well as the electronic medical record.
• Consults, provides professional expertise to and collaborates with clinical documentation specialists on coding and documentation practices and standards.
• Maintains active and up-to-date coding certification by meeting continuing education requirements.
• Performs other duties as assigned.

Required Experience & Qualifications

• Coding Certification (ie. CCS, CCA, CPC)
• Strong knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process
• Knowledge of MS DRG prospective payment system and severity systems
• Ability to concentrate for extended periods of time
• Ability to work and make decisions independently

Preferred Experience & Qualifications

• Electronic Medical Record system experience
• Hospital-based coding experience

Physical Demands

• Good vision and hearing.
• Operate typewriter or computer keyboard, answer phones, open file drawers.
• Must be able to communicate orally.

Special Notes

• Resume/CV should be included with the online application.
• Stony Brook Medicine is a smoke-free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
• This function/position maybe 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 Eastern Long Island and related facilities.