Coder Medical Record II

• Reviews Emergency Department medical records and assigns accurate ICD-10-CM, CPT®, and HCPCS Level II codes for diagnoses, procedures, treatments, and services in accordance with Official Coding Guidelines, Medicare regulations, New York State requirements, and third-party payer policies.
• Ensures appropriate code assignment to support compliant reimbursement methodologies, including APC classification and outpatient payment systems.
• Analyzes provider documentation to determine accurate code selection and identifies opportunities for documentation improvement.
• Queries physicians and other licensed practitioners when documentation is incomplete, conflicting, ambiguous, or insufficient to support accurate code assignment.
• Abstracts clinical and demographic data from the medical record and enters coded information into designated coding and billing systems.
• Reviews coded encounters for accuracy, completeness, and compliance prior to final billing and claim submission.
• Monitors and validates data integrity within the billing system to ensure optimal reimbursement and regulatory compliance.
• Identifies cases requiring mandatory reporting, including reportable diseases, trauma registries, and other regulatory reporting requirements, as applicable.
• Identifies potential cancer cases and other reportable conditions for referral to appropriate registries and reporting programs.
• Performs ongoing audits and quality reviews to ensure coding accuracy, consistency, and adherence to organizational standards.
• Reports coding, documentation, compliance, or reimbursement concerns to Coding Leadership and/or appropriate clinical staff for resolution.
• Assists with coding-related audits, denials management, payer reviews, compliance investigations, and regulatory requests.
• Provides coding expertise and supports special projects, studies, quality initiatives, and data requests for leadership, committees, and regulatory agencies.
• Maintains current knowledge of coding regulations, reimbursement methodologies, documentation requirements, and industry best practices through continuing education and professional development activities.
• Participates in departmental meetings, education sessions, and training programs to maintain competency and implement new coding guidelines and payer requirements.
• Reviews and monitors new clinical terminology, abbreviations, and documentation practices for compliance with organizational standards.
• Maintains strict confidentiality of patient, physician, and organizational information in accordance with HIPAA, organizational policies, and applicable privacy regulations.
• Adheres to the AHIMA Code of Ethics, Standards of Ethical Coding, and all applicable compliance and regulatory requirements.
• Demonstrates flexibility to work varying schedules, shifts, overtime, or weekends as operational needs require.
• Performs other duties and responsibilities as assigned by Coding Leadership, HIM Management, or Department Administration.

Qualifications

• Associate degree in Health Information Management or related field preferred.
• Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Coding Associate (CCA), or equivalent coding credential preferred.
• Minimum of 2 years of Emergency Department, outpatient, or facility coding experience preferred.
• Thorough knowledge of ICD-10-CM, CPT®, HCPCS, APC methodology, Medicare regulations, and New York State reporting requirements.
• Strong analytical, problem-solving, communication, and organizational skills.
• Proficiency with electronic health records, encoder software, and computerized billing and abstracting systems.

Competencies

• Coding Accuracy and Compliance
• Clinical Documentation Review
• Regulatory Knowledge
• Revenue Cycle Awareness
• Critical Thinking and Decision-Making
• Attention to Detail
• Data Integrity and Quality Assurance
• Professional Ethics and Confidentiality
• Effective Communication and Physician Collaboration

Shift -

•  Mon, Wed, & Friday 8 am-1:50 pm
• Tues & Thurs 8 am-4:45 pm

Hourly $39.5077 - $42.999