ON SITE Certified Medical Records Coder - Per Diem - Eastern Long Island Hospital

About the role

The selected candidate will work on-site in Greenport, NY for all shifts. This is not a remote or hybrid opportunity.

Job Duties & Essential Functions

• Abstracts and codes medical information from Inpatient and/or Outpatient charts into the organization's 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 Specialists when necessary, prior to final coding.
• Adheres to department standards for productivity and accuracy.
• Identifies and trends coding issues and escalates 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).
• Knowledge of electronic medical records and 3M or Encoder System.
• 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.