Medical Record Coder jobs at Northwell Health

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records. Job Responsibility 1.Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment. 2.Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes. 3.Utilizes resources and reference materials (e.g., manuals, online resources: Official Coding Guidelines (OCG), AHA Coding Clinic, Center for Medicare Services and CPT Assistant) to identify appropriate codes and reference code applicability, rules and guidelines. 4.Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/ or coding references to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient's acuity, severity of illness and risk of mortality (if applicable), as documented in the medical record. 5.Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures. 6.Accurately assigns discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations. 7.Make determinations on medical coding and takes initiative to complete reviews and coding independently, to avoid delays in the workflow process. 8.Manages multiple work demands simultaneously to maintain relevant efficiency and turnaround time standards for completing coding/DRG assignment. 9.Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection, Congenital Malformations and Expirations. 10.For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets. 11.Assigns appropriate discharge physician in the system. 12.Generates compliant physician queries to clarify any incomplete/ambiguous or conflicting documentation and applies post-query responses to make final coding determinations. 13.Demonstrates basic knowledge of the impact of coding decisions on revenue cycle. 14.Assists in the education of physicians and other clinicians by advocating proper documentation practices, further specificity, resequencing and inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity of illness and risk of mortality as indicated. 15.Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines and regulations. 16.Completes moderately complex assignments that require an ability to recognize the need to occasionally deviate from accepted practices. 17.Exercises independent judgment on basic or moderately complex issues regarding job and related tasks. 18.Works independently under minimal supervision within established guidelines and procedures. 19.Requires minimal instruction on day-to-day work; majority of work is self-directed; receives instruction on new assignments. 20.Works with lead on resolution of day-to-day technical/procedural challenges. 21.May provide work guidance to team members to ensure accurate and timely completion of tasks. 22.Performs related duties, as required. *ADA Essential Functions Job Qualification High School Diploma or equivalent required. 3 - 5 years of technical experience, required. One or more of the following required: Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician (CCSP) or Certified Inpatient Coder (CIC) or Certified Outpatient Coder (COC) or RHIA or RHIT certification. Inpatient facility coding experience, preferred. *Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

Responsible for the review and coding of inpatient and/or ambulatory surgery records utilizing ICD-10-CM and ICD-10-PCS or CPT coding guidelines and conventions for the establishment of diagnoses and procedures. The coded data is utilized for reimbursement, clinical care assessment, education, research, case mix and health care statistical reporting. Education Requirements Coding certificate, CCA. CCS (inpatient) or CCS-P (outpatient) certification preferred. Experience Requirements Minimum of 2 years inpatient/outpatient coding experience in acute tertiary care hospital Proficiency in the use of automated coding and DRG/AOC grouping software. Licensing and Certification Requirements (if applicable) Name: Certified Coding Specialist (CCS) Issuing Agency: American Academy of Professional Coders (AAPC) Collective bargaining unit: SEIU 1199-MSH SEIU 1199 at Mount Sinai Hospital, 183 - Medical Records - MSH, Mount Sinai Hospital 1.Reviews, analyzes and codes inpatient and/or ambulatory (outpatient) surgery records utilizing all prevailing coding guidelines and conventions for the establishment of diagnoses and procedures. 2.Queries physicians for clarification of documentation if required. 3.Participates in the documentation improvement process on conjunction with Coding management and leadership. 4.Consistently meets or exceeds coding productivity standards as per department policies. 5.Ensures compliance with CMS and other regulatory compliance guidelines. 6.Participates in continuing education opportunities as set forth by Coding leadership. Acquires continuing education hours to maintain certification(s). 7.Promotes and contributes to the collaboration between HIM in a positive manner and serves as mentors to junior coding staff. 8.Other responsibilities as required.

Responsible for the review and coding of inpatient and/or ambulatory surgery records utilizing ICD-10-CM and ICD-10-PCS or CPT coding guidelines and conventions for the establishment of diagnoses and procedures. The coded data is utilized for reimbursement, clinical care assessment, education, research, case mix and health care statistical reporting. **Qualifications** **Education Requirements** Coding certificate, CCA. CCS (inpatient) or CCS-P (outpatient) certification preferred. **Experience Requirements** Minimum of 2 years inpatient/outpatient coding experience in acute tertiary care hospital Proficiency in the use of automated coding and DRG/AOC grouping software. **Licensing and Certification Requirements (if applicable)** Name: Certified Coding Specialist (CCS) Issuing Agency: American Academy of Professional Coders (AAPC) Collective bargaining unit: SEIU 1199-MSH SEIU 1199 at Mount Sinai Hospital, 183 - Medical Records - MSH, Mount Sinai Hospital **Responsibilities** 1.Reviews, analyzes and codes inpatient and/or ambulatory (outpatient) surgery records utilizing all prevailing coding guidelines and conventions for the establishment of diagnoses and procedures. 2.Queries physicians for clarification of documentation if required. 3.Participates in the documentation improvement process on conjunction with Coding management and leadership. 4.Consistently meets or exceeds coding productivity standards as per department policies. 5.Ensures compliance with CMS and other regulatory compliance guidelines. 6.Participates in continuing education opportunities as set forth by Coding leadership. Acquires continuing education hours to maintain certification(s). 7.Promotes and contributes to the collaboration between HIM in a positive manner and serves as mentors to junior coding staff. 8.Other responsibilities as required. **About Us** **Strength through Unity and Inclusion** The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai's unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual. At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history. **About the Mount Sinai Health System:** Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time - discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients' medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report's "Best Children's Hospitals" ranks Mount Sinai Kravis Children's Hospital among the country's best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek's "The World's Best Smart Hospitals" ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally. **Equal Opportunity Employer** The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization. **Compensation Statement** Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $39.877 - $39.877 Hourly. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

Department/Unit: Health Information Services Work Shift: Day (United States of America) Salary Range: $55,895.80 - $83,843.71The Hospital Coder applies skills and knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services (including substances, equipment, supplies, or other items used in the provision of healthcare services). This position is responsible for selecting and sequencing the codes such that the organization receives the optimal reimbursement to which the facility is legally entitled, remembering that it is unethical and illegal to increase reimbursement by means that contradict requirements. Essential Duties and Responsibilities Use a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD-10-CM/PCS, CPT4, Uniform Hospital Discharge Data Set (UHDDS), Medicare, Medicaid and other fiscal intermediary guidelines. Support the reporting of healthcare data elements (e.g. diagnoses and procedure codes, hospital acquired conditions, patient safety indicators) required for external reporting purposes (e.g. reimbursement, value based purchasing initiatives and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements, as well as all applicable official coding conventions, rules, and guidelines. Query the provider (physician or other qualified healthcare practitioner), whether verbal or written, for clarification and/or additional documentation when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicators). Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. Advances coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. Utilizes official coding rules and guidelines apply the most accurate coding to represent that patient services on the hospital claim. Comply with comprehensive internal coding policies and procedures that are consistent with requirements. Attends coding meetings and roundtable sessions. Participates in daily huddles and LEAN problem-solving activities. Focused with no distractions while working and participating in meetings. Ensures camera on while attending Teams calls. Assists with organizing the shared drive for the medical coding department. Other duties as assigned by manager. Qualifications High School Diploma/G.E.D. - required Prior experience in hospital medical coding - preferred Prior experience with 3M 360 and EPIC system - preferred Applicants must receive a score of 80% or above on assessment. Will consider new coders with a higher assessment score. (High proficiency) Excellent computer skills, navigating multiple systems at once, troubleshooting. (High proficiency) Must be able to work independently as position is fully remote. Maintain a remote coding work area that protects confidential health information. (High proficiency) Excellent written and verbal communication skills. (High proficiency) Knowledge of ICD-10-CM, and ICD-10-PCS or CPT-4 Coding classification system, depending on the position being hired for. (High proficiency) Detail-oriented and efficient while maintaining productivity. Coding certification / credential through AHIMA or AAPC and be in good standing. - required Equivalent combination of relevant education and experience may be substituted as appropriate. Physical Demands Standing - Occasionally Walking - Occasionally Sitting - Constantly Lifting - Rarely Carrying - Rarely Pushing - Rarely Pulling - Rarely Climbing - Rarely Balancing - Rarely Stooping - Rarely Kneeling - Rarely Crouching - Rarely Crawling - Rarely Reaching - Rarely Handling - Occasionally Grasping - Occasionally Feeling - Rarely Talking - Frequently Hearing - Frequently Repetitive Motions - Frequently Eye/Hand/Foot Coordination - Frequently Working Conditions Extreme cold - Rarely Extreme heat - Rarely Humidity - Rarely Wet - Rarely Noise - Occasionally Hazards - Rarely Temperature Change - Rarely Atmospheric Conditions - Rarely Vibration - Rarely Thank you for your interest in Albany Medical Center! Albany Medical Center is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Department/Unit: Health Information Services Work Shift: Day (United States of America) Salary Range: $55,895.80 - $83,843.71The Hospital Coder applies skills and knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services (including substances, equipment, supplies, or other items used in the provision of healthcare services). This position is responsible for selecting and sequencing the codes such that the organization receives the optimal reimbursement to which the facility is legally entitled, remembering that it is unethical and illegal to increase reimbursement by means that contradict requirements. Essential Duties and Responsibilities Use a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD-10-CM/PCS, CPT4, Uniform Hospital Discharge Data Set (UHDDS), Medicare, Medicaid and other fiscal intermediary guidelines. Support the reporting of healthcare data elements (e.g. diagnoses and procedure codes, hospital acquired conditions, patient safety indicators) required for external reporting purposes (e.g. reimbursement, value based purchasing initiatives and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements, as well as all applicable official coding conventions, rules, and guidelines. Query the provider (physician or other qualified healthcare practitioner), whether verbal or written, for clarification and/or additional documentation when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicators). Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. Advances coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. Utilizes official coding rules and guidelines apply the most accurate coding to represent that patient services on the hospital claim. Comply with comprehensive internal coding policies and procedures that are consistent with requirements. Attends coding meetings and roundtable sessions. Participates in daily huddles and LEAN problem-solving activities. Focused with no distractions while working and participating in meetings. Ensures camera on while attending Teams calls. Assists with organizing the shared drive for the medical coding department. Other duties as assigned by manager. Qualifications High School Diploma/G.E.D. - required Prior experience in hospital medical coding - preferred Prior experience with 3M 360 and EPIC system - preferred Applicants must receive a score of 80% or above on assessment. Will consider new coders with a higher assessment score. (High proficiency) Excellent computer skills, navigating multiple systems at once, troubleshooting. (High proficiency) Must be able to work independently as position is fully remote. Maintain a remote coding work area that protects confidential health information. (High proficiency) Excellent written and verbal communication skills. (High proficiency) Knowledge of ICD-10-CM, and ICD-10-PCS or CPT-4 Coding classification system, depending on the position being hired for. (High proficiency) Detail-oriented and efficient while maintaining productivity. Coding certification / credential through AHIMA or AAPC and be in good standing. - required Equivalent combination of relevant education and experience may be substituted as appropriate. Physical Demands Standing - Occasionally Walking - Occasionally Sitting - Constantly Lifting - Rarely Carrying - Rarely Pushing - Rarely Pulling - Rarely Climbing - Rarely Balancing - Rarely Stooping - Rarely Kneeling - Rarely Crouching - Rarely Crawling - Rarely Reaching - Rarely Handling - Occasionally Grasping - Occasionally Feeling - Rarely Talking - Frequently Hearing - Frequently Repetitive Motions - Frequently Eye/Hand/Foot Coordination - Frequently Working Conditions Extreme cold - Rarely Extreme heat - Rarely Humidity - Rarely Wet - Rarely Noise - Occasionally Hazards - Rarely Temperature Change - Rarely Atmospheric Conditions - Rarely Vibration - Rarely Thank you for your interest in Albany Medical Center! Albany Medical Center is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

To perform complex clerical duties requiring independent judgment relating to the storage, retrieval and maintenance of medical records. Performs clerical work requiring application of various work methods and procedures and familiarity with Medical Record Department functions, policies, and practices. Is responsible for providing service to the patients/customers of the Hospital Center. Is cognizant of the philosophy, standards, objectives and policies of the Medical Record Department and the Hospital Center. High School graduation or its equivalent plus at least 2-3 years of prior medical record department experience. Associates Degree preferred. None required, Registered Health Information Technology Certification preferred, RHIT (Registered Health Information Technician). Collective bargaining unit: SEIU 1199-MSW Compensation Statement The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $26.10 - $28.04 Hourly. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits. SEIU 1199 at Mount Sinai West, BCF - Medical Records - WST, Mount Sinai West Clinical/Technical/Service 1. Demonstrates the ability to perform technical/service/clerical tasks. 2. Retrieve medical records for all requestors and prints necessary documents from appropriate medical record systems. 3. Receives, checks, edits, assembles, analyzes, sorts (alphabetically or numerically) 4. Purges medical record documents and reports, conducting research when necessary. 5. Scans documents and reports into the Epic EMR, OnBase Document Imaging/Records Management system and performing scanning functions on the nursing units. 6. Utilizes departmental systems, including META-chart tracking, Eagle Information System, EPIC EMR, QUIC Lists, OnBase, M MODAL transcription/dictation System, CIOX correspondence, etc., to locate, maintain and update information required to perform duties. 7. Performs research to efficiently merge EMR and hard copy medical records and demographic data as required to ensure visit history information is the same as information in the Eagle registration system. 8. Performs data entry, data inquiry and data updates. 9. Prepares reports and medical records for the OnBase Imaging/Records Management System including scanning and chart auditing 10. Indexes records and information through manual or automatic indexing; assigns document types and reviews hard copy documents that have been captured during scanning. 11. Responds to inquiries regarding deficiencies, documentation requirements and physician assignment. 12. Responds to requests for information from third party requesters (physicians, insurers, attorneys, courts of law, etc.) including subpoenas. 13. Performs photocopying of complete medical records and medical record abstracts for requesters. 14. Tracks dictation sent to and received from transcription service. 15. Verifies and validates transcription services reports. 16. Receives, sorts and routes incoming mail, as required. 17. Provides front desk and telephone coverage and may act as receptionist or as backup for another member of the clerical staff. 18. Manually and electronically prepares and mails incomplete and delinquent record notification letters to physicians. 19. Provides daily productivity and statistical information to supervisor/manager. 20. Performs quality control verification for departmental processes and systems. 21. Maintains established hospital/departmental/unit policies, procedures, objectives, quality assurance, safety, environmental and infection control. 22. Assists in the care and maintenance of department equipment, including reporting systems problems to Help Desk and/or appropriate departmental staff 23. Attends meetings as required, including in-service education meetings. 24. Demonstrates the knowledge and skills necessary to provide care, based on physical, psychosocial, education, safety, and related criteria, appropriate to the age of the patients served in assigned area. Organizational/Managerial 1.Participates in the departments performance improvement activities. 2.Maintains patient/employee confidentiality in the management of information. 3.Observes the Health Care Systems compliance policies. 4.May be required to perform other duties as assigned or perform other duties when necessary. Education/Professional Development 1.Participates in the development of other staff members. 2.Meets regulatory, licenser and annual health assessment requirements. 3.Identifies learning strengths and needs. 4.Utilizes learning resources Communication/Relationships 1.Demonstrates a professional, courteous, and respectful attitude in dealing with patients, families and significant others. 2.Displays courtesy, tact and patience during interactions with all members of the hospital and extended community. Attendance and Punctuality 1.Adheres to the Hospital Centers policy on attendance and punctuality.

To perform complex clerical duties requiring independent judgment relating to the storage, retrieval and maintenance of medical records. Performs clerical work requiring application of various work methods and procedures and familiarity with Medical Record Department functions, policies, and practices. Is responsible for providing service to the patients/customers of the Hospital Center. Is cognizant of the philosophy, standards, objectives and policies of the Medical Record Department and the Hospital Center. **Qualifications** High School graduation or its equivalent plus at least 2-3 years of prior medical record department experience. Associates Degree preferred. None required, Registered Health Information Technology Certification preferred, RHIT (Registered Health Information Technician). Collective bargaining unit: SEIU 1199-MSW **Compensation Statement** The Mount Sinai Health System (MSHS) provides salary ranges that comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $26.10 - $28.04 Hourly. Actual salaries depend on a variety of factors, including experience, education, and operational need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits. SEIU 1199 at Mount Sinai West, BCF - Medical Records - WST, Mount Sinai West **Responsibilities** **Clinical/Technical/Service** 1. Demonstrates the ability to perform technical/service/clerical tasks. 2. Retrieve medical records for all requestors and prints necessary documents from appropriate medical record systems. 3. Receives, checks, edits, assembles, analyzes, sorts (alphabetically or numerically) 4. Purges medical record documents and reports, conducting research when necessary. 5. Scans documents and reports into the Epic EMR, OnBase Document Imaging/Records Management system and performing scanning functions on the nursing units. 6. Utilizes departmental systems, including META-chart tracking, Eagle Information System, EPIC EMR, QUIC Lists, OnBase, M MODAL transcription/dictation System, CIOX correspondence, etc., to locate, maintain and update information required to perform duties. 7. Performs research to efficiently merge EMR and hard copy medical records and demographic data as required to ensure visit history information is the same as information in the Eagle registration system. 8. Performs data entry, data inquiry and data updates. 9. Prepares reports and medical records for the OnBase Imaging/Records Management System including scanning and chart auditing 10. Indexes records and information through manual or automatic indexing; assigns document types and reviews hard copy documents that have been captured during scanning. 11. Responds to inquiries regarding deficiencies, documentation requirements and physician assignment. 12. Responds to requests for information from third party requesters (physicians, insurers, attorneys, courts of law, etc.) including subpoenas. 13. Performs photocopying of complete medical records and medical record abstracts for requesters. 14. Tracks dictation sent to and received from transcription service. 15. Verifies and validates transcription services reports. 16. Receives, sorts and routes incoming mail, as required. 17. Provides front desk and telephone coverage and may act as receptionist or as backup for another member of the clerical staff. 18. Manually and electronically prepares and mails incomplete and delinquent record notification letters to physicians. 19. Provides daily productivity and statistical information to supervisor/manager. 20. Performs quality control verification for departmental processes and systems. 21. Maintains established hospital/departmental/unit policies, procedures, objectives, quality assurance, safety, environmental and infection control. 22. Assists in the care and maintenance of department equipment, including reporting systems problems to Help Desk and/or appropriate departmental staff 23. Attends meetings as required, including in-service education meetings. 24. Demonstrates the knowledge and skills necessary to provide care, based on physical, psychosocial, education, safety, and related criteria, appropriate to the age of the patients served in assigned area. **Organizational/Managerial** 1.Participates in the departments performance improvement activities. 2.Maintains patient/employee confidentiality in the management of information. 3.Observes the Health Care Systems compliance policies. 4.May be required to perform other duties as assigned or perform other duties when necessary. **Education/Professional Development** 1.Participates in the development of other staff members. 2.Meets regulatory, licenser and annual health assessment requirements. 3.Identifies learning strengths and needs. 4.Utilizes learning resources **Communication/Relationships** 1.Demonstrates a professional, courteous, and respectful attitude in dealing with patients, families and significant others. 2.Displays courtesy, tact and patience during interactions with all members of the hospital and extended community. **Attendance and Punctuality** 1.Adheres to the Hospital Centers policy on attendance and punctuality. **About Us** **Strength through Unity and Inclusion** The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai's unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual. At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history. **About the Mount Sinai Health System:** Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time - discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients' medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report's "Best Children's Hospitals" ranks Mount Sinai Kravis Children's Hospital among the country's best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek's "The World's Best Smart Hospitals" ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally. **Equal Opportunity Employer** The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization. **Compensation Statement** Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $26.1044 - $28.0397 Hourly. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

Department/Unit: Health Information Services Work Shift: Day (United States of America) Salary Range: $55,895.80 - $83,843.71 The Hospital Coder applies skills and knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services (including substances, equipment, supplies, or other items used in the provision of healthcare services). This position is responsible for selecting and sequencing the codes such that the organization receives the optimal reimbursement to which the facility is legally entitled, remembering that it is unethical and illegal to increase reimbursement by means that contradict requirements. Essential Duties and Responsibilities * Use a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD-10-CM-CPT4. * Support the reporting of healthcare data elements (e.g. diagnoses and procedure codes, hospital acquired conditions, patient safety indicators) required for external reporting purposes (e.g. reimbursement, value based purchasing initiatives and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements, as well as all applicable official coding conventions, rules, and guidelines. * Query the provider (physician or other qualified healthcare practitioner), whether verbal or written, for clarification and/or additional documentation when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicators). Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. * Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. * Advances coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. * Utilizes official coding rules and guidelines apply the most accurate coding to represent that patient services on the hospital claim. * Comply with comprehensive internal coding policies and procedures that are consistent with requirements. * Attends coding meetings and roundtable sessions. * * Focused with no distractions while working and participating in meetings. * Ensures camera on while attending Teams calls. * Assists with organizing the shared drive for the medical coding department. * Other duties as assigned by manager. Qualifications * High School Diploma/G.E.D. - required * Prior experience in hospital medical coding - preferred * Prior experience with 3M 360 and EPIC system - preferred * Applicants must receive a score of 80% or above on assessment. Will consider new coders with a higher assessment score. (High proficiency) * Excellent computer skills, navigating multiple systems at once, troubleshooting. (High proficiency) * Must be able to work independently as position is fully remote. Maintain a remote coding work area that protects confidential health information. (High proficiency) * Excellent written and verbal communication skills. (High proficiency) * Knowledge of ICD-10-CM, and ICD-10-PCS or CPT-4 Coding classification system, depending on the position being hired for. (High proficiency) * Detail-oriented and efficient while maintaining productivity. * Coding certification / credential through AHIMA or AAPC and be in good standing. - required Equivalent combination of relevant education and experience may be substituted as appropriate. Physical Demands * Standing - Occasionally * Walking - Occasionally * Sitting - Constantly * Lifting - Rarely * Carrying - Rarely * Pushing - Rarely * Pulling - Rarely * Climbing - Rarely * Balancing - Rarely * Stooping - Rarely * Kneeling - Rarely * Crouching - Rarely * Crawling - Rarely * Reaching - Rarely * Handling - Occasionally * Grasping - Occasionally * Feeling - Rarely * Talking - Frequently * Hearing - Frequently * Repetitive Motions - Frequently * Eye/Hand/Foot Coordination - Frequently Working Conditions * Extreme cold - Rarely * Extreme heat - Rarely * Humidity - Rarely * Wet - Rarely * Noise - Occasionally * Hazards - Rarely * Temperature Change - Rarely * Atmospheric Conditions - Rarely * Vibration - Rarely Thank you for your interest in Albany Medical Center! Albany Medical Center is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Department/Unit: Health Information Services Work Shift: Day (United States of America) Salary Range: $55,895.80 - $83,843.71 The Hospital Coder applies skills and knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services (including substances, equipment, supplies, or other items used in the provision of healthcare services). This position is responsible for selecting and sequencing the codes such that the organization receives the optimal reimbursement to which the facility is legally entitled, remembering that it is unethical and illegal to increase reimbursement by means that contradict requirements. Essential Duties and Responsibilities * Use a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD-10-CM/PCS, CPT4, Uniform Hospital Discharge Data Set (UHDDS), Medicare, Medicaid and other fiscal intermediary guidelines. * Support the reporting of healthcare data elements (e.g. diagnoses and procedure codes, hospital acquired conditions, patient safety indicators) required for external reporting purposes (e.g. reimbursement, value based purchasing initiatives and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements, as well as all applicable official coding conventions, rules, and guidelines. * Query the provider (physician or other qualified healthcare practitioner), whether verbal or written, for clarification and/or additional documentation when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicators). Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. * Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. * Advances coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. * Utilizes official coding rules and guidelines apply the most accurate coding to represent that patient services on the hospital claim. * Comply with comprehensive internal coding policies and procedures that are consistent with requirements. * Attends coding meetings and roundtable sessions. * Participates in daily huddles and LEAN problem-solving activities. * Focused with no distractions while working and participating in meetings. * Ensures camera on while attending Teams calls. * Assists with organizing the shared drive for the medical coding department. * Other duties as assigned by manager. Qualifications * High School Diploma/G.E.D. - required * Prior experience in hospital medical coding - preferred * Prior experience with 3M 360 and EPIC system - preferred * Applicants must receive a score of 80% or above on assessment. Will consider new coders with a higher assessment score. (High proficiency) * Excellent computer skills, navigating multiple systems at once, troubleshooting. (High proficiency) * Must be able to work independently as position is fully remote. Maintain a remote coding work area that protects confidential health information. (High proficiency) * Excellent written and verbal communication skills. (High proficiency) * Knowledge of ICD-10-CM, and ICD-10-PCS or CPT-4 Coding classification system, depending on the position being hired for. (High proficiency) * Detail-oriented and efficient while maintaining productivity. * Coding certification / credential through AHIMA or AAPC and be in good standing. - required Equivalent combination of relevant education and experience may be substituted as appropriate. Physical Demands * Standing - Occasionally * Walking - Occasionally * Sitting - Constantly * Lifting - Rarely * Carrying - Rarely * Pushing - Rarely * Pulling - Rarely * Climbing - Rarely * Balancing - Rarely * Stooping - Rarely * Kneeling - Rarely * Crouching - Rarely * Crawling - Rarely * Reaching - Rarely * Handling - Occasionally * Grasping - Occasionally * Feeling - Rarely * Talking - Frequently * Hearing - Frequently * Repetitive Motions - Frequently * Eye/Hand/Foot Coordination - Frequently Working Conditions * Extreme cold - Rarely * Extreme heat - Rarely * Humidity - Rarely * Wet - Rarely * Noise - Occasionally * Hazards - Rarely * Temperature Change - Rarely * Atmospheric Conditions - Rarely * Vibration - Rarely Thank you for your interest in Albany Medical Center! Albany Medical Center is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

To perform complex clerical duties requiring independent judgment relating to the storage, retrieval and maintenance of medical records. Performs clerical work requiring application of various work methods and procedures and familiarity with Medical Record Department functions, policies, and practices. Is responsible for providing service to the patients/customers of the Hospital Center. Cognizant of the philosophy, standards, objectives and policies of the Medical Record Department and the Hospital Center **Qualifications** **_Requirements:_** + High School graduation or its equivalent plus at least 2-3 years of prior medical record department experience. Associates Degree preferred. + Working knowledge of business English, spelling, arithmetic, office practices and procedures, and or departmental rules and regulations + Ability to understand and carry out oral and written instructions and to request clarification when needed + Ability to maintain established records and files; ability to meet the public well and to deal effectively with their questions or problems seeking assistance + Ability to communicate effectively, orally and in writing; may be required to type at a rate of least 35 words per minute and/ or operate a computer system. + Registered Health Information Technology Certification preferred, RHIT. Collective bargaining unit: OPEIU Local 153-MSB OPEIU Local 153 at Mount Sinai Brooklyn, ACK - Medical Records - BKL, Mount Sinai Brooklyn **Responsibilities** **_Roles & Responsibilities:_** + Job demonstrates the ability to perform technical/service/clerical tasks. + Retrieve medical records for all requestors and prints necessary documents from appropriate medical record systems. + Provides front desk and telephone coverage for department. + Processes daily discharge reports and verifies all discharges are received according to policy and procedure. + Purges medical record documents and reports, conducting research when necessary. + Preps, Scans and Indexes documents and reports into the Epic EMR, OnBase Document Imaging/Records Management system. + Utilizes departmental systems, including META-chart tracking, Eagle Information System, EPIC EMR, QUIC Lists, OnBase, MMODAL transcription/dictation System, CIOX correspondence, etc., to locate, maintain and update information required to perform duties. + Performs research to efficiently merge EMR and hard copy medical records and demographic data as required to ensure visit history information is the same as information in the Eagle registration system. + Performs data entry, data inquiry and data updates. + Prepares reports and medical records for the OnBase Imaging/Records Management System including scanning and chart auditing + Indexes records and information through manual or automatic indexing; assigns document types. + Responds to inquiries regarding deficiencies, documentation requirements and physician assignment. + Responds to requests for information from third party requesters (physicians, insurers, attorneys, courts of law, etc.) including subpoenas. + Performs photocopying of complete medical records and medical record abstracts for requesters. + Tracks dictation sent to and received from transcription service. + Verifies and validates transcription services reports. + Receives, sorts and routes incoming mail, as required. + Validates Authorizations on all incoming medical records request are valid and HIPAA compliant + Manually and electronically prepares and mails incomplete and delinquent record notification letters to physicians. + Provides daily productivity and statistical information to supervisor/manager. + Performs quality control verification for departmental processes and systems. + Maintains established hospital/departmental/unit policies, procedures, objectives, quality assurance, safety, environmental and infection control. + Assists in the care and maintenance of department equipment, including reporting systems problems to Help Desk and/or appropriate departmental staff. + Attends meetings as required, including in-service education meetings. **Organizational/Managerial** + Participates in the department's performance improvement activities. + Maintains patient/employee confidentiality in the management of information. + Observes the Health Care System's compliance policies. + May be required to perform other duties as assigned or perform other duties when necessary. **Education/Professional Development** + Participates in the development of other staff members + Meets regulatory, licenser and annual health assessment requirements. + Identifies learning strengths and needs. + Utilizes learning resources **Communication/Relationships** + Demonstrates a professional, courteous, and respectful attitude in dealing with patients, families and significant others. + Displays courtesy, tact and patience during interactions with all members of the hospital and extended community. **About Us** **Strength through Unity and Inclusion** The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai's unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual. At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history. **About the Mount Sinai Health System:** Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time - discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients' medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report's "Best Children's Hospitals" ranks Mount Sinai Kravis Children's Hospital among the country's best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek's "The World's Best Smart Hospitals" ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally. **Equal Opportunity Employer** The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization. **Compensation Statement** Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $24.6625 - $24.6625 Hourly. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.

Connecticut Children's is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children's offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our transformational growth establishes us as a destination for specialized medicine and enables us to reach more children in locations that are closer to home. Our breakthrough research, superior education and training, innovative community partnerships, and commitment to diversity, equity and inclusion provide a welcoming and inspiring environment for our patients, families and team members. At Connecticut Children's, treating children isn't just our job - it's our passion. As a leading children's health system experiencing steady growth, we're excited to expand our team with exceptional team members who share our vision of transforming children's health and well-being as one team. The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual health information for data retrieval, analysis, and claims processing. * Experience Preferred: Successful completion of a coding certificate program with AHIMA approval status preferred. * Education Required: Associate degree or equivalent training acquired through at least three years on-the-job experience. * Certification is required within one year of hire; acceptable certifications for this position include: * American Health Information Management Association (AHIMA): RHIA, RHIT, CCS, CCS-P, CCA * American Academy of Professional Coders (AAPC). Knowledge, Skills and Abilities: Knowledge of: * Coding guidelines for using ICD-9-CM (Volumes 1, 2, and 3), ICD-10-CM, ICD-10-PCS, CPT and HCPCS Level II codes in inpatient and outpatient settings. * Extensive knowledge of anatomy and medical terminology. * Maintains, and increases knowledge of issues that affect coding and billing and the healthcare industry. * Regulatory requirements pertaining to healthcare operations in the practice and hospital settings. * ICD-9-CM (Vol 1, 2, and 3) Official Coding Guidelines. * ICD-10-CM Official Coding Guidelines. * ICD-10-PCS Official Coding Guidelines. * CPT and HCPCS Level II Coding Guidelines including Evaluation & Management Coding, Surgical Coding, and the use of Modifiers. * Data management techniques. Skills: * Advanced Computer skills, PC experience w/ Windows-based applications. * Communication skills including strong verbal, written, and interpersonal skills. * Keyboarding skills with ability to type 40 wpm minimum. Ability to: * Analyze complex medical records and identify billable services. * Work with individuals at all levels within the organization and the community; effectively communicate with providers. * Manage and prioritize workloads to meet deadlines. * Research coding questions. * Gather, review and compile information and prepare reports, often with deadlines. * Maintain quality and compliance standards. * Maintain confidentiality of information. * Function in a fast-paced environment with strong attention to detail meeting productivity and accuracy standards. * The coder abstracts pertinent information from patient records and assigns ICD-9-CM/ICD-10-CM, ICD-10-PCS or CPT/HCPCS codes, creating APC or DRG group assignments. * Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes. * The coder keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department manager for resolution. * Abides by the standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. * Documentation assessment and review for accurate abstracting of clinical data to meet regulatory and compliance requirements. The coder assists in coordination of the compilation of data relative to regulatory agencies and the accreditation process. * Review all charges, ensure accurate charge capture and review medical necessity for all ordered tests/procedures. * Perform coding and charge capture for facility services including but not limited to emergency department and IV services. Charge capture may include providers' services. * Monitor coding work queues for simple visit coding including rehabilitation services. * Proactively communicate with physicians and physician's offices to insure adequate documentation to support ordered services. * Verify accuracy of patient account/type and demographic data and coordinates with patient financial services to assure accurate billing/reimbursement and reporting. * The coder displays initiative and supports continuous quality improvement efforts. He/she performs special projects, training, education, and/or other duties as assigned. * Continuously evaluate the quality of clinical documentation to spot incomplete or inconsistent documentation for inpatient encounters that impact code selection and resulting DRG groups. * Monitor unbilled account reports for outstanding or uncoded discharges. * Reviews bills and payments to insure correct billing and reimbursement. * Audits, corrects, and submits any denials as appropriate. Possess knowledge and understanding of discharge, not final billed (DNFB) parameters. * Abstracts data for special projects and quality initiatives * Effectively uses of software to follow through on accuracy of claim submission. * Effectively communicates with patient financial services to resolve coding and billing questions or concerns.

To perform complex clerical duties requiring independent judgment relating to the storage, retrieval and maintenance of medical records. Performs clerical work requiring application of various work methods and procedures and familiarity with Medical Record Department functions, policies, and practices. Is responsible for providing service to the patients/customers of the Hospital Center. Cognizant of the philosophy, standards, objectives and policies of the Medical Record Department and the Hospital Center Requirements: High School graduation or its equivalent plus at least 2-3 years of prior medical record department experience. Associates Degree preferred. Working knowledge of business English, spelling, arithmetic, office practices and procedures, and or departmental rules and regulations Ability to understand and carry out oral and written instructions and to request clarification when needed Ability to maintain established records and files; ability to meet the public well and to deal effectively with their questions or problems seeking assistance Ability to communicate effectively, orally and in writing; may be required to type at a rate of least 35 words per minute and/ or operate a computer system. Registered Health Information Technology Certification preferred, RHIT. Collective bargaining unit: OPEIU Local 153-MSB OPEIU Local 153 at Mount Sinai Brooklyn, ACK - Medical Records - BKL, Mount Sinai Brooklyn Roles & Responsibilities: Job demonstrates the ability to perform technical/service/clerical tasks. Retrieve medical records for all requestors and prints necessary documents from appropriate medical record systems. Provides front desk and telephone coverage for department. Processes daily discharge reports and verifies all discharges are received according to policy and procedure. Purges medical record documents and reports, conducting research when necessary. Preps, Scans and Indexes documents and reports into the Epic EMR, OnBase Document Imaging/Records Management system. Utilizes departmental systems, including META-chart tracking, Eagle Information System, EPIC EMR, QUIC Lists, OnBase, MMODAL transcription/dictation System, CIOX correspondence, etc., to locate, maintain and update information required to perform duties. Performs research to efficiently merge EMR and hard copy medical records and demographic data as required to ensure visit history information is the same as information in the Eagle registration system. Performs data entry, data inquiry and data updates. Prepares reports and medical records for the OnBase Imaging/Records Management System including scanning and chart auditing Indexes records and information through manual or automatic indexing; assigns document types. Responds to inquiries regarding deficiencies, documentation requirements and physician assignment. Responds to requests for information from third party requesters (physicians, insurers, attorneys, courts of law, etc.) including subpoenas. Performs photocopying of complete medical records and medical record abstracts for requesters. Tracks dictation sent to and received from transcription service. Verifies and validates transcription services reports. Receives, sorts and routes incoming mail, as required. Validates Authorizations on all incoming medical records request are valid and HIPAA compliant Manually and electronically prepares and mails incomplete and delinquent record notification letters to physicians. Provides daily productivity and statistical information to supervisor/manager. Performs quality control verification for departmental processes and systems. Maintains established hospital/departmental/unit policies, procedures, objectives, quality assurance, safety, environmental and infection control. Assists in the care and maintenance of department equipment, including reporting systems problems to Help Desk and/or appropriate departmental staff. Attends meetings as required, including in-service education meetings. Organizational/Managerial Participates in the department's performance improvement activities. Maintains patient/employee confidentiality in the management of information. Observes the Health Care System's compliance policies. May be required to perform other duties as assigned or perform other duties when necessary. Education/Professional Development Participates in the development of other staff members Meets regulatory, licenser and annual health assessment requirements. Identifies learning strengths and needs. Utilizes learning resources Communication/Relationships Demonstrates a professional, courteous, and respectful attitude in dealing with patients, families and significant others. Displays courtesy, tact and patience during interactions with all members of the hospital and extended community.

Department/Unit: Health Information Services Work Shift: Day (United States of America) Salary Range: $60,367.47 - $90,551.20The Senior Hospital Coder is responsible for performing detailed coding quality audits, scheduled and random, on staff and providing thorough education and feedback, projects assigned by management, and special requests to review coding for external departments such as quality management and CDI. Responsible for monitoring and tracking trends of staff, bringing forward concerns to leadership regarding coding quality and productivity, completes duties as assigned by the Quality Manager. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. Senior Hospital Coder may be asked to assist with denials work, including researching and writing appeal letters. These individuals are highly skilled and considered experts in medical coding. Essential Duties and Responsibilities Optimize hospital reimbursement by auditing and monitoring inpatient and outpatient records and investigating unbilled cases. Understands the hospital inpatient/outpatient and CBO billing and registration systems. Assist with educating providers, clinicians, and others by advocating proper documentation practices and further specificity for both diagnoses and procedures when needed to more precisely reflect the acuity, severity, and the occurrence of events. Bring to the attention of the organization management any identified inappropriate coding practices that do not comply with requirements. Assist in problem solving processes and workgroups, including participating in the development of query policies that support documentation improvement and meet regulatory, legal, and ethical standards for coding and reporting. Assist leadership in team collaboration, leading meetings and onboarding new staff. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. Responsible for communicating both verbally and written to physicians, clinical departments, medical coders, and management teams. Query and/or consult as needed with the provider for clarification and additional documentation prior to final code assignment in accordance with acceptable healthcare industry practices. Provides feedback to coding staff on quality scores. Communicates with management when trends or concerns arise regarding poor quality. Schedules calls and is available for coding staff when they have questions related to coding. Leads a morning huddle one week each quarter in a 12-month calendar year. Communicates to Coding Support Specialist on topics for monthly meetings. Research new coding clinics, guidelines, and concepts and provides education to staff. Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. Research coding forums and coding issues related to registration status. Works with a multitude of software systems at once, navigating efficiently between them. These systems include Meditech, Soarian Clinicals and Financials, 3M HDM and 360, Outlook, MS Teams, Word, Outlook, Excel, Glens Falls Hospital Citrix, Saratoga Hospital Citrix. Assists with organizing the shared drive for the medical coding department. Assist in development and compliance of comprehensive internal coding policies and procedures that are consistent with requirements. Actively participates in discussions and projects to improve turnaround time for coding. Participates in daily huddles and LEAN problem-solving activities. Demonstrates change-leadership skills. Supporting the collaboration of coders to improve inefficiencies and solve problems. Connect with coders when necessary. Being a mentor and guide to their success. Qualifications High School Diploma/G.E.D. - required Associate's Degree In Health Information Management or related program - preferred 1-3 years Experience in a leadership, supervision, or code auditing position providing quality feedback to staff. - required 2 or more years of experience coding ICD-10-CM/PCS and/or CPT coding. - required Experience with 3M 360 and EPIC - preferred Applicants must receive a minimum score of 85% on a coding assessment. (High proficiency) Expert level with reading a medical record to assign ICD-10-CM, ICD-10-PCS, and CPT4 codes, abstract data elements for billing and reporting, and assign DRG, APC, and APG as appropriate. (High proficiency) Highly skilled in team development, critical thinking, organization, verbal, and written communication. Skilled in team-oriented job tasks with providing detail and accuracy, strong customer service skills. (High proficiency) Ability to work independently and effectively with a team. Knowledge in revenue cycle operations. (High proficiency) Coding certification / credential through AHIMA or AAPC and be in good standing - required RHIT / RHIA - preferred Equivalent combination of relevant education and experience may be substituted as appropriate. Physical Demands Standing - Occasionally Walking - Occasionally Sitting - Constantly Lifting - Rarely Carrying - Rarely Pushing - Rarely Pulling - Rarely Climbing - Rarely Balancing - Rarely Stooping - Rarely Kneeling - Rarely Crouching - Rarely Crawling - Rarely Reaching - Rarely Handling - Occasionally Grasping - Occasionally Feeling - Rarely Talking - Frequently Hearing - Frequently Repetitive Motions - Frequently Eye/Hand/Foot Coordination - Frequently Working Conditions Extreme cold - Rarely Extreme heat - Rarely Humidity - Rarely Wet - Rarely Noise - Occasionally Hazards - Rarely Temperature Change - Rarely Atmospheric Conditions - Rarely Vibration - Rarely Thank you for your interest in Albany Medical Center! Albany Medical Center is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Department/Unit: Health Information Services Work Shift: Day (United States of America) Salary Range: $60,367.47 - $90,551.20 The Senior Hospital Coder is responsible for performing detailed coding quality audits, scheduled and random, on staff and providing thorough education and feedback, projects assigned by management, and special requests to review coding for external departments such as quality management and CDI. Responsible for monitoring and tracking trends of staff, bringing forward concerns to leadership regarding coding quality and productivity, completes duties as assigned by the Quality Manager. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. Senior Hospital Coder may be asked to assist with denials work, including researching and writing appeal letters. These individuals are highly skilled and considered experts in medical coding. Essential Duties and Responsibilities * Optimize hospital reimbursement by auditing and monitoring inpatient and outpatient records and investigating unbilled cases. * Understands the hospital inpatient/outpatient and CBO billing and registration systems. * Assist with educating providers, clinicians, and others by advocating proper documentation practices and further specificity for both diagnoses and procedures when needed to more precisely reflect the acuity, severity, and the occurrence of events. Bring to the attention of the organization management any identified inappropriate coding practices that do not comply with requirements. * Assist in problem solving processes and workgroups, including participating in the development of query policies that support documentation improvement and meet regulatory, legal, and ethical standards for coding and reporting. * Assist leadership in team collaboration, leading meetings and onboarding new staff. * Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. * Responsible for communicating both verbally and written to physicians, clinical departments, medical coders, and management teams. * Query and/or consult as needed with the provider for clarification and additional documentation prior to final code assignment in accordance with acceptable healthcare industry practices. * Provides feedback to coding staff on quality scores. * Communicates with management when trends or concerns arise regarding poor quality. * Schedules calls and is available for coding staff when they have questions related to coding. * Leads a morning huddle one week each quarter in a 12-month calendar year. * Communicates to Coding Support Specialist on topics for monthly meetings. * Research new coding clinics, guidelines, and concepts and provides education to staff. * Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. * Research coding forums and coding issues related to registration status. * Works with a multitude of software systems at once, navigating efficiently between them. These systems include Meditech, Soarian Clinicals and Financials, 3M HDM and 360, Outlook, MS Teams, Word, Outlook, Excel, Glens Falls Hospital Citrix, Saratoga Hospital Citrix. * Assists with organizing the shared drive for the medical coding department. * Assist in development and compliance of comprehensive internal coding policies and procedures that are consistent with requirements. * Actively participates in discussions and projects to improve turnaround time for coding. * Participates in daily huddles and LEAN problem-solving activities. * Demonstrates change-leadership skills. Supporting the collaboration of coders to improve inefficiencies and solve problems. * Connect with coders when necessary. Being a mentor and guide to their success. Qualifications * High School Diploma/G.E.D. - required * Associate's Degree In Health Information Management or related program - preferred * 1-3 years Experience in a leadership, supervision, or code auditing position providing quality feedback to staff. - required * 2 or more years of experience coding ICD-10-CM/PCS and/or CPT coding. - required * Experience with 3M 360 and EPIC - preferred * Applicants must receive a minimum score of 85% on a coding assessment. (High proficiency) * Expert level with reading a medical record to assign ICD-10-CM, ICD-10-PCS, and CPT4 codes, abstract data elements for billing and reporting, and assign DRG, APC, and APG as appropriate. (High proficiency) * Highly skilled in team development, critical thinking, organization, verbal, and written communication. Skilled in team-oriented job tasks with providing detail and accuracy, strong customer service skills. (High proficiency) * Ability to work independently and effectively with a team. Knowledge in revenue cycle operations. (High proficiency) * Coding certification / credential through AHIMA or AAPC and be in good standing - required * RHIT / RHIA - preferred Equivalent combination of relevant education and experience may be substituted as appropriate. Physical Demands * Standing - Occasionally * Walking - Occasionally * Sitting - Constantly * Lifting - Rarely * Carrying - Rarely * Pushing - Rarely * Pulling - Rarely * Climbing - Rarely * Balancing - Rarely * Stooping - Rarely * Kneeling - Rarely * Crouching - Rarely * Crawling - Rarely * Reaching - Rarely * Handling - Occasionally * Grasping - Occasionally * Feeling - Rarely * Talking - Frequently * Hearing - Frequently * Repetitive Motions - Frequently * Eye/Hand/Foot Coordination - Frequently Working Conditions * Extreme cold - Rarely * Extreme heat - Rarely * Humidity - Rarely * Wet - Rarely * Noise - Occasionally * Hazards - Rarely * Temperature Change - Rarely * Atmospheric Conditions - Rarely * Vibration - Rarely Thank you for your interest in Albany Medical Center! Albany Medical Center is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Medical Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Department/Unit: Patient Engagement Center Work Shift: Day (United States of America) Salary Range: $40,495.10 - $52,643.64 This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. The Pre-Service Representative I is responsible for the initial touchpoint of our patient population to provide an exceptional patient experience with assisting in scheduling of services for our Hospital and Practice. This requires ability to work in a high-volume, fast paced environment. Understanding of complex scheduling needs of our patients in an empathetic, compassionate manner is critical. Position is required to use eligibility application to invoke request to verify insurance eligibility, interpret response and capture appropriate health insurance information as it pertains to the service being rendered. The position requires ability to understand and apply contractual benefits to the service being rendered, with ability to collect patient financial obligation pre-services. The Pre-Service Representative I, after one year in the position and based on performance and success in position, has ability to be promoted to Pre-Service Representative II as Career Ladder requirements indicate. Education: * HS Graduate Licensure, Certification & Registration: * None Experience: * 1 - 2 years Winning customer service personality with ability to engage patients and customers via telephone with superior patient experience. * Insurance knowledge, preferred Skills, Knowledge & Abilities: * Proven customer service skill with ability to exceed expectations * Ability to multi-task in stressful and high patient volume unit * Must be able to manage pressure of very tight timeframes to execute task * Ability to learn in classroom, utilizing resources * Ability to maintain composure under pressure * Ability to review information and draw appropriate conclusion * Good judgement and ability to be resourceful to problem solve; escalate issues as needed * Team minded worth ethic * Demonstrated ability interpret patient's insurance benefits and apply the applicable contractual obligations Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a "need to know" and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Department/Unit: Patient Engagement Center Work Shift: Day (United States of America) Salary Range: $40,495.10 - $52,643.64This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification. The Pre-Service Representative I is responsible for the initial touchpoint of our patient population to provide an exceptional patient experience with assisting in scheduling of services for our Hospital and Practice. This requires ability to work in a high-volume, fast paced environment. Understanding of complex scheduling needs of our patients in an empathetic, compassionate manner is critical. Position is required to use eligibility application to invoke request to verify insurance eligibility, interpret response and capture appropriate health insurance information as it pertains to the service being rendered. The position requires ability to understand and apply contractual benefits to the service being rendered, with ability to collect patient financial obligation pre-services. The Pre-Service Representative I, after one year in the position and based on performance and success in position, has ability to be promoted to Pre-Service Representative II as Career Ladder requirements indicate. Education: HS Graduate Licensure, Certification & Registration: None Experience: 1 - 2 years Winning customer service personality with ability to engage patients and customers via telephone with superior patient experience. Insurance knowledge, preferred Skills, Knowledge & Abilities: Proven customer service skill with ability to exceed expectations Ability to multi-task in stressful and high patient volume unit Must be able to manage pressure of very tight timeframes to execute task Ability to learn in classroom, utilizing resources Ability to maintain composure under pressure Ability to review information and draw appropriate conclusion Good judgement and ability to be resourceful to problem solve; escalate issues as needed Team minded worth ethic Demonstrated ability interpret patient's insurance benefits and apply the applicable contractual obligations Thank you for your interest in Albany Medical Center! Albany Medical is an equal opportunity employer. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records. Job Responsibility 1.Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment. 2.Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes. 3.Utilizes resources and reference materials (e.g., manuals, online resources: Official Coding Guidelines (OCG), AHA Coding Clinic, Center for Medicare Services and CPT Assistant) to identify appropriate codes and reference code applicability, rules and guidelines. 4.Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/ or coding references to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient's acuity, severity of illness and risk of mortality (if applicable), as documented in the medical record. 5.Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures. 6.Accurately assigns discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations. 7.Make determinations on medical coding and takes initiative to complete reviews and coding independently, to avoid delays in the workflow process. 8.Manages multiple work demands simultaneously to maintain relevant efficiency and turnaround time standards for completing coding/DRG assignment. 9.Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection, Congenital Malformations and Expirations. 10.For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets. 11.Assigns appropriate discharge physician in the system. 12.Generates compliant physician queries to clarify any incomplete/ambiguous or conflicting documentation and applies post-query responses to make final coding determinations. 13.Demonstrates basic knowledge of the impact of coding decisions on revenue cycle. 14.Assists in the education of physicians and other clinicians by advocating proper documentation practices, further specificity, resequencing and inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity of illness and risk of mortality as indicated. 15.Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines and regulations. 16.Completes moderately complex assignments that require an ability to recognize the need to occasionally deviate from accepted practices. 17.Exercises independent judgment on basic or moderately complex issues regarding job and related tasks. 18.Works independently under minimal supervision within established guidelines and procedures. 19.Requires minimal instruction on day-to-day work; majority of work is self-directed; receives instruction on new assignments. 20.Works with lead on resolution of day-to-day technical/procedural challenges. 21.May provide work guidance to team members to ensure accurate and timely completion of tasks. 22.Performs related duties, as required. *ADA Essential Functions Job Qualification High School Diploma or equivalent required. 3 - 5 years of technical experience, required. One or more of the following required: Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician (CCSP) or Certified Inpatient Coder (CIC) or Certified Outpatient Coder (COC) or RHIA or RHIT certification. Inpatient facility coding experience, preferred. *Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

Reviews, analyzes and resolves accounts that have failed coding and charging related claim edits, including departments requiring clinical/coding expertise. Responsible for validation of items, assuring the appropriate assignment of coding system, modifier(s) and revenue codes, by reviewing medical record documentation, facility protocol, regulatory guidance and other applicable documentation. Job Responsibility Adheres to regulations and maintains a reasonable understanding of the billing process to ensure that hospital procedures and services are properly ordered. Coordinates with ancillary departments regarding the instruction of appropriate charge capture and regulatory guidelines. Identifies front-end process improvement initiatives; monitors coding changes for governmental agencies and other payers; educates departments on coding and compliance issues. Ensures revenue codes are in compliance with the Federal Register and other regulatory agencies. Uses various coding resources, including researching availability of additional documentation to assign accurate codes. Keeps abreast of federal regulatory agencies and changes in coding and reimbursement. Involved in coding system conversion projects in which new facilities are added to coding system structure. Serves as the coding resource with charge capture knowledge during coding system departmental reviews with responsibilities including voluminous charge validation and corporate mapping of each charge by department. Operates under general guidance and work assignments are varied and require interpretation and independent decisions on course of action. Performs related duties as required. All responsibilities noted here are considered essential functions of the job under the Americans with Disabilities Act. Duties not mentioned here, but considered related are not essential functions. Job Qualification Bachelor's Degree required, or equivalent combination of education and related experience. Current Professional Coder Certification, or Current Coding Professional Certification required, plus specialized certifications as needed. 1-3 years of relevant experience, required. *Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future.When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records. Job Responsibility 1.Analyzes and interprets the medical record in its entirety to ensure accurate, complete and consistent selection of diagnoses and procedures to assure the production of quality healthcare data and accurate facility payment. 2.Applies understanding of basic anatomy and physiology to interpret clinical documentation and identify applicable codes. 3.Utilizes resources and reference materials (e.g., manuals, online resources: Official Coding Guidelines (OCG), AHA Coding Clinic, Center for Medicare Services and CPT Assistant) to identify appropriate codes and reference code applicability, rules and guidelines. 4.Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/ or coding references to select the principal diagnosis, secondary diagnoses, all significant procedures, indicating the patient's acuity, severity of illness and risk of mortality (if applicable), as documented in the medical record. 5.Codes and reports diagnoses and their associated present on Admission (POA) Indicator and procedures. 6.Accurately assigns discharge disposition for all records as required and in accordance with the Centers for Medicare and Medicaid Services (CMS) rules and regulations. 7.Make determinations on medical coding and takes initiative to complete reviews and coding independently, to avoid delays in the workflow process. 8.Manages multiple work demands simultaneously to maintain relevant efficiency and turnaround time standards for completing coding/DRG assignment. 9.Assigns and reports all other data elements required for Statewide Planning and Research Cooperative System (SPARCS) data collection, Congenital Malformations and Expirations. 10.For outpatient encounters, applies coding conventions and official coding guidelines approved by the Current Procedural Terminology (CPT) rules established by the American Medical Association (AMA), and any other official rules and guidelines established for use with the mandated outpatient procedure code sets. 11.Assigns appropriate discharge physician in the system. 12.Generates compliant physician queries to clarify any incomplete/ambiguous or conflicting documentation and applies post-query responses to make final coding determinations. 13.Demonstrates basic knowledge of the impact of coding decisions on revenue cycle. 14.Assists in the education of physicians and other clinicians by advocating proper documentation practices, further specificity, resequencing and inclusion of diagnoses or procedures when needed to more accurately reflect the acuity, severity of illness and risk of mortality as indicated. 15.Attends and participates in required hospital education programs in order to maintain and enhance their coding skills and stay abreast of changes in codes, coding guidelines and regulations. 16.Completes moderately complex assignments that require an ability to recognize the need to occasionally deviate from accepted practices. 17.Exercises independent judgment on basic or moderately complex issues regarding job and related tasks. 18.Works independently under minimal supervision within established guidelines and procedures. 19.Requires minimal instruction on day-to-day work; majority of work is self-directed; receives instruction on new assignments. 20.Works with lead on resolution of day-to-day technical/procedural challenges. 21.May provide work guidance to team members to ensure accurate and timely completion of tasks. 22.Performs related duties, as required. * ADA Essential Functions Job Qualification * High School Diploma or equivalent required. * 3 - 5 years of technical experience, required. * One or more of the following required: Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) or Certified Coding Specialist-Physician (CCSP) or Certified Inpatient Coder (CIC) or Certified Outpatient Coder (COC) or RHIA or RHIT certification. * Inpatient facility coding experience, preferred. * Additional Salary Detail The salary range and/or hourly rate listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining a team member's base salary and/or rate, several factors may be considered as applicable (e.g., location, specialty, service line, years of relevant experience, education, credentials, negotiated contracts, budget and internal equity).