Medical Coder jobs at Albany Medical Center

Department/Unit: Health Information Services Work Shift: Day (United States of America) Salary Range: $40,495.10 - $52,643.64The HIM Technician is responsible for supporting the health information management processes within the Albany Med Health System (AMHS). This entry-level position focuses on the retrieval, preparation, scanning and indexing of clinical documentation for AMHS' inpatient and outpatient facilities. The HIM Technician ensures compliance with legal, regulatory, and organizational standards while maintaining the Integrity and confidentiality of patient information. Essential Duties and Responsibilities Assist the HIM Operations Manager to ensure all clinical documentation is available to coding/billing and clinical staff via the electronic health record within 24 hours of discharge. Retrieves and sorts clinical documentation from departments when directed by the HIM leadership team. Prepares clinical documentation to be scanned by reconciling encounters, orders, referrals, etc. Follows up on incomplete records per departmental reconciliation guidelines. Prep, scan and index incoming clinical documentation from internal providers and external referrers in accordance with departmental policies and procedures. Performs a thorough review of all incoming documents via mail, faz, email, etc. and redirects them to the appropriate departments accordingly. Identifies documents, which constitute the legal content of the patient's health record, in both electronic and paper formats to ensure integrity of record. Assigns appropriate document types and supporting identifiers such as date of service. Assists in the collection and reporting of quality metrics related to PCMH and CMS quality measures by adhering to departmental policies that target appropriate mapping of the medical record (patient, encounter, or order level). Identify contents of incoming paper and electronic clinical documentation to appropriately reroute documents to physician, nurse, referral team or other department in accordance with department policies and procedures. Properly completes destruction of records once prep, scan, index, and QA processing has been fulfilled. Understands departmental record retention schedule and assists with tasks related to storing, retention, and purging patient records. Meets productivity and quality benchmarks and scorecard expectations set by the HIM Operations Manager. Collaborate with the team to enhance data accuracy and integrity of medical records. Notify HIM leadership of any workflow or build issues to mitigate potential problems as soon as possible. Performs other tasks and projects assigned by the HIM leadership team. Takes proactive steps to recognize active or potential security risks and report them to qualified IT staff or supervisor. Adaps to the diversity of the customer to understand complex issues. Qualifications High School Diploma/G.E.D. - required . Will consider an associates degree in HIM with a minimum of 80 hours of practical experience in HIM in a hospital setting in lieu of work experience. - required Familiarity with EHR systems, ideally EPIC and OnBase. Basic understanding of Patient-Centered Medical Home (PCMH) and Centers for Medicare and Medicaid Services (CMS) quality measures. Ability to organize and establish day-today priorities Ability to multitask while remaining professional, focused, compused, and positive Excellent customer service skills Displays Integrity, friendliness and compassion Must be able to establish an appropriate and effective rapport with patients, coworkers, and medical staff Must be able to demonstrate effective and appropriate written and oral communication skills Ability to take and follow direction in a positive and appropriate manner Must be flexible Takes initiative/able to work independently Embraces new opportunities to grow both personally and organizationally Must be efficient and effective in the use of resources Basic computer skills such as but not limited to Excel, Work, and Microsoft Teams Ability to read and understand the English language Ability to effectively maintain confidentiality of records and communicate with all levels of personnel RHIA, RHIT - 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 - Constantly Hearing - Constantly 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.

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.

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.

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.

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.

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). The salary range for this position is $64,350-$98,500/year It is Northwell Health's policy to provide equal employment opportunity and treat all applicants and employees equally regardless of their age, race, creed/religion, color, national origin, immigration status or citizenship status, sexual orientation, military or veteran status, sex/gender, gender identity, gender expression, disability, pregnancy, genetic information or genetic predisposition or carrier status, marital or familial status, partnership status, victim of domestic violence, sexual or other reproductive health decisions, or other characteristics protected by applicable law.

Provides guidance to team members to ensure proficient operation of the Patient Financial Services department. Functions as a liaison between physicians' and ancillary departments in the instruction of regulatory guidelines. Researches and resolves complex assignments. Job Responsibility + Monitors system files to ensure the efficient, expeditious processing of all re-billed encounters; identifies and implements solutions to process issues as needed. Researches and resolves complex assignments; serves as on-site resource for coding and charging issues. Responsible for in servicing coding/clinical staff of changes that take place in the coding system; encourages communication between departments to resolve coding and billing issues. Validates coding system maintenance forms prepared by Financial Analysts in a timely manner; ensures coding system codes and revenue codes are in compliance with the Federal Register and other regulatory agencies. Uses all coding resources, including researching availability of additional documentation to assign accurate system codes; monitors code editor report to analyze, research and resolve issues related to Medicare outpatient claims that generate code editor edits. + Maintains current knowledge base of regulatory & coding guidelines, billing processes, Ambulatory Payment Classification (APC) groups, federal, state and regulatory agency coding and reimbursement changes and coding requirements to ensure hospital procedures and services are properly ordered and charged for. + Conducts departmental coding/documentation audits to identify the education needs of the department; assists in the education of the outpatient revenue specialists as identified through the audit process. Conducts educational sessions with department staff, Department Heads and clinical staff members to ensure proper maintenance procedures. + Operates under limited guidance and work assignments involve moderately complex to complex issues where the analysis of situations or data requires in-depth evaluation of variable factors. + 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. + 3-5 years of relevant experience, required. + Prior experience with hospital Inpatient coding, preferred. + Proficient in Excel, 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). The salary range for this position is $70,470-$116,870/year It is Northwell Health's policy to provide equal employment opportunity and treat all applicants and employees equally regardless of their age, race, creed/religion, color, national origin, immigration status or citizenship status, sexual orientation, military or veteran status, sex/gender, gender identity, gender expression, disability, pregnancy, genetic information or genetic predisposition or carrier status, marital or familial status, partnership status, victim of domestic violence, sexual or other reproductive health decisions, or other characteristics protected by applicable law.

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). The salary range for this position is $66,220.05-$108,179.96/year It is Northwell Health's policy to provide equal employment opportunity and treat all applicants and employees equally regardless of their age, race, creed/religion, color, national origin, immigration status or citizenship status, sexual orientation, military or veteran status, sex/gender, gender identity, gender expression, disability, pregnancy, genetic information or genetic predisposition or carrier status, marital or familial status, partnership status, victim of domestic violence, sexual or other reproductive health decisions, or other characteristics protected by applicable law.

Performs coding and abstracting duties to assure accurate completion of coding for all assigned patient records. Logs all discharges into the computerized Discharge Log, enters specific data elements and verifies the discharge physician for all coded records. Serves as an onsite resource for both inpatient and outpatient coding issues. Maintains an understanding of both Inpatient and Outpatient Prospective Payment Systems. Job Responsibility 1. Assigns codes accurately to each record for diagnoses and procedures performed according to ICD-9-CM and CPT-4 coding and classification systems 2. (This includes assignment of 'modifiers' on required cases).Utilizes resources needed to adhere to coding guidelines (e.g 3. Coding Clinic, Coding Handbook, etc.) 4. Also uses reference materials (medical dictionary, Physicians Desk Reference, approved abbreviations) to ensure accuracy to align with Coding Compliance Regulations (Department of Justice/OIG).Abstracts data from the medical record and enters data directly into the 3M Application software 5. (Utilizes data sheet only when needed during downtime) 6. Responds correctly to prompts for refining of codes as well as tracking case managed patients, readmission status, discharge disposition, birth weight, O.R 7. minutes, lesion size, type of anesthesia and ASA classification..Obtains corresponding pathology reports to ensure accurate coding to support documentation within the record 8. Works in concert with DRG Validator on 'DRG Assurance' 9. Verifies proposed DRG to ensure accurate assignment for direct relationship to finance and reimbursement.Meets the required productivity and competency levels established for a full time Inpatient Coder 10. (Inpatient:20 ) Meets productivity and competency standards for coding of Ambulatory Surgical records for a full time employee.(Outpatient:36) Codes pre-admission surgical testing forms on assigned day.Codes and enters discharges/re-admits at time of receipt from transferring unit.Completes DOH forms for appropriate records, i.e 11. Spontaneous Termination of Pregnancy, Alzheimer's, Congenital Malformation, Induced Termination of Pregnancy, and Sterilization.Responsible for submitting DOH forms to the responsible person in a timely manner to ensure DOH Regulations are met 12. Keeps a log of all forms sent.Assists in data audits as requested 13. Responds to suggestions for change in timely manner.Assigns charts to appropriate review area for coding validation check.Responds to physician's coding questions when necessary.Performs related duties as required.*ADA Essential FunctionsPhysical Demands: Requires the ability to sit for long periods of time, high visual activity to review documents, high level of concentration without allowing distraction to impact workflow. 14. High School Graduate or equivalent, required.Completion of one-year Coding Certification program or equivalent experience in coding, required.Credentialed CCS/RHIT, Required.One year of coding experience in an acute care setting with a complex case Mix and a skill level required to perform the job with accuracy.Requires excellent knowledge ICD-9 and CPT-4 coding principles.Requires good interpersonal skills in order to interact effectively with physicians and reviewers.Requires knowledge of medical terminology, anatomy and physiology. The salary range for this position is $39.00-$50.51/hour It is Northwell Health's policy to provide equal employment opportunity and treat all applicants and employees equally regardless of their age, race, creed/religion, color, national origin, immigration status or citizenship status, sexual orientation, military or veteran status, sex/gender, gender identity, gender expression, disability, pregnancy, genetic information or genetic predisposition or carrier status, marital or familial status, partnership status, victim of domestic violence, sexual or other reproductive health decisions, or other characteristics protected by applicable law.

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).

Provides guidance to team members to ensure proficient operation of the Patient Financial Services department. Functions as a liaison between physicians' and ancillary departments in the instruction of regulatory guidelines. Researches and resolves complex assignments. Job Responsibility Monitors system files to ensure the efficient, expeditious processing of all re-billed encounters; identifies and implements solutions to process issues as needed. Researches and resolves complex assignments; serves as on-site resource for coding and charging issues. Responsible for in servicing coding/clinical staff of changes that take place in the coding system; encourages communication between departments to resolve coding and billing issues. Validates coding system maintenance forms prepared by Financial Analysts in a timely manner; ensures coding system codes and revenue codes are in compliance with the Federal Register and other regulatory agencies. Uses all coding resources, including researching availability of additional documentation to assign accurate system codes; monitors code editor report to analyze, research and resolve issues related to Medicare outpatient claims that generate code editor edits. Maintains current knowledge base of regulatory & coding guidelines, billing processes, Ambulatory Payment Classification (APC) groups, federal, state and regulatory agency coding and reimbursement changes and coding requirements to ensure hospital procedures and services are properly ordered and charged for. Conducts departmental coding/documentation audits to identify the education needs of the department; assists in the education of the outpatient revenue specialists as identified through the audit process. Conducts educational sessions with department staff, Department Heads and clinical staff members to ensure proper maintenance procedures. Operates under limited guidance and work assignments involve moderately complex to complex issues where the analysis of situations or data requires in-depth evaluation of variable factors. 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. 3-5 years of relevant experience, required. Prior experience with hospital Inpatient coding, preferred. Proficient in Excel, 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).

Conducts concurrent and occasionally onsite medical chart reviews for pediatric and neonatal ICU patients. Collaborates with medical directors and staff to enhance the quality of physician documentation, ensuring a precise representation of the patients' severity of illness, anticipated risk of mortality, and the complexity of care administered. Ensures the accuracy, completeness, and compliance of medical coding and documentation for all pediatric patient encounters. Strives to optimize coding practices, minimize denials, and maintain the highest standards of data integrity. Job Responsibility 1.Analyzes and interprets complex pediatric medical records to ensure accurate capture and coding of diagnoses, procedures, and appropriate levels of service, adhering to established coding guidelines ( ICD-10-CM, CPT, HCPCS). 2.Applies advanced knowledge of pediatric anatomy, physiology, and medical terminology to interpret clinical documentation and assign the most accurate and speific codes. 3.Leverages coding resources, reference materials (e.g. online coding platforms, coding manuals, payer policies), and internal expertise to ensure accurate code selection, understand coding rules, and apply guidelines effectively. 4.3Demonstrates a comprehensive understanding of the impact of coding decisions on the revenue cycle, including reimbursement, denials, and compliance. 5.Proactively facilitates clarification of provider clinical documentation to ensure accuracy, completeness, and integrity in the medical record, using effective communication techniques. 6.Maintains strict adherence to all government regulations), departmental policies, and contractual agreements related to coding and billing practices. 7.Performs comprehensive internal audits of coding practices to identify areas for improvement, reduce coding errors, and mitigate potential compliance risks. 8.Develops and implements corrective action plans to address identified coding deficiencies. 9.Collaborates effectively with physicians, nurses, and other healthcare providers to clarify documentation ambiguities, resolve coding discrepancies, and ensure accurate and complete medical records. 10.Acts as a coding resource for other members of the clinical and administrative teams in real-time. 11.Develops and delivers targeted feedback and training to providers on documentation and coding best practices, focusing on areas for improvement and compliance requirements. 12.Creates and maintains educational materials related to coding and documentation guidelines. 13.Actively stays abreast of changes in coding guidelines, regulations (e.g., CMS updates, payer-specific policies), and coding software updates. 14.Proactively enhances coding skills through continuing education, professional certifications, and participation in industry conferences and webinars. 15.Stays updated on the latest advancements in pediatric medicine and their impact on coding practices Job Qualification •High School Diploma or equivalent required. •3 - 5 years of technical experience, required. •Minimum 1 year experience in pediatric coding and documentation at acute care facility, required. •CPC certification, required. CPEDC certification, preferred. This position follows a hybrid model, with 1-2 on-site days per week and the remainder remote. *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. Logs all discharges into the computerized Discharge Log, enters specific data elements and verifies the discharge physician for all coded records. Serves as an onsite resource for both inpatient and outpatient coding issues. Maintains an understanding of both Inpatient and Outpatient Prospective Payment Systems. Job Responsibility * Assigns codes accurately to each record for diagnoses and procedures performed according to ICD-9-CM and CPT-4 coding and classification systems * (This includes assignment of "modifiers" on required cases).Utilizes resources needed to adhere to coding guidelines (e.g * Coding Clinic, Coding Handbook, etc.) * Also uses reference materials (medical dictionary, Physicians Desk Reference, approved abbreviations) to ensure accuracy to align with Coding Compliance Regulations (Department of Justice/OIG).Abstracts data from the medical record and enters data directly into the 3M Application software * (Utilizes data sheet only when needed during downtime) * Responds correctly to prompts for refining of codes as well as tracking case managed patients, readmission status, discharge disposition, birth weight, O.R * minutes, lesion size, type of anesthesia and ASA classification..Obtains corresponding pathology reports to ensure accurate coding to support documentation within the record * Works in concert with DRG Validator on "DRG Assurance" * Verifies proposed DRG to ensure accurate assignment for direct relationship to finance and reimbursement.Meets the required productivity and competency levels established for a full time Inpatient Coder * (Inpatient:20 ) Meets productivity and competency standards for coding of Ambulatory Surgical records for a full time employee.(Outpatient:36) Codes pre-admission surgical testing forms on assigned day.Codes and enters discharges/re-admits at time of receipt from transferring unit.Completes DOH forms for appropriate records, i.e * Spontaneous Termination of Pregnancy, Alzheimer's, Congenital Malformation, Induced Termination of Pregnancy, and Sterilization.Responsible for submitting DOH forms to the responsible person in a timely manner to ensure DOH Regulations are met * Keeps a log of all forms sent.Assists in data audits as requested * Responds to suggestions for change in timely manner.Assigns charts to appropriate review area for coding validation check.Responds to physician's coding questions when necessary.Performs related duties as required.*ADA Essential FunctionsPhysical Demands: Requires the ability to sit for long periods of time, high visual activity to review documents, high level of concentration without allowing distraction to impact workflow. * High School Graduate or equivalent, required.Completion of one-year Coding Certification program or equivalent experience in coding, required.Credentialed CCS/RHIT, Required.One year of coding experience in an acute care setting with a complex case Mix and a skill level required to perform the job with accuracy.Requires excellent knowledge ICD-9 and CPT-4 coding principles.Requires good interpersonal skills in order to interact effectively with physicians and reviewers.Requires knowledge of medical terminology, anatomy and physiology.

• Performs ICD-10-CM diagnostic and current procedural terminology procedural coding to maintain an accurate database and ensure accurate coding at minimum accuracy rate of 95%. • Competent in the utilization of an electronic medical record, and computerized coding/abstracting systems. • Applies the Uniform Hospital Discharge Data Set (UHDDS) definitions as well as any additional regulatory guidelines and/or coding references to select diagnosis and all significant procedures, indicating the patient's acuity, severity of illness and risk of mortality (if applicable) and all charges as documented in the medical record. • Applies knowledge of ambulatory payment classification reimbursement for procedure coding, current procedural terminology guidelines, knowledge of local coverage determination's for medical necessity, and appropriate use of modifiers. • Effectively and professionally communicates with providers to clarify documentation in order to assign accurate diagnoses and procedures for ambulatory payment classification and for medical necessity. • Ability to code using either 3M encoder or ICD-9-CM/ICD-10-CM book. • Performs E/M (Evaluation Management) coding for physician and facility with a minimum accuracy of 95%. • 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. • Maintains certified coding credentials in accordance with the certified coding requirements and demonstrates annual compliance. • Achieves the organization's established expectations with regard to customer service, teamwork and safety. • Responds to all questions regarding diagnoses and procedures with the billing office in a timely manner. • Fulfills all compliance responsibilities related to the position. • Performs other duties as assigned. Education, Skills, Experience Essential: CPC, COC, CCS, or CCS-P certification Required: Specialized training in medical terminology, ICD-10-CM Diagnosis, CPT procedure and E/M coding. Able to decipher operative reports, medical orders, and various medical records in the appropriate selection of codes. Experience in acute care coding with outpatient records. Minimum Experience: 2 years demonstrated coding experience in appropriate application of coding and documentation guidelines Desired: Course work in Anatomy and Physiology. Education * HS Graduate or Equivalent *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).

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.