Coder Level 3

4 weeks ago

Brooklyn, United States Mount Sinai Hospital Full time
Job Description

Responsible for coding and analysis of complex inpatient medical records, utilizing ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification)ICD-10-CM (International Classification of Diseases 10th revision) coding guidelines and conventions for establishment of diagnosis and procedures. The coded information is utilized for reimbursement purposes, data retrieval, education, to support medical research activity, assessment of clinical care, evaluation of medical services, case mix for the facility, and identification of health care concerns for public health.

Responsibilities

Medical Records - InPatient Coder - THIS IS AN ON-SITE POSITION
  1. Thoroughly review, analyze, and interpret the entire medical record (electronic and hardcopy), including progress notes, consultation reports, physician orders, nursing notes, operative reports, pathology reports, radiology reports, laboratory results, medication records, other ancillary service reports, and the discharge summary to identify all diagnoses and procedures occurring/affecting the current admission.
  2. Apply knowledge of anatomy and physiology, disease process, pharmacology, to identify diagnoses and procedures documented in the medical record.
  3. Apply knowledge of the ICD-9-CM, ICD-10-CM coding system to translate identified diagnoses and procedures to codes for accurate reimbursement and data.
  4. Adhere to Official ICD-9-CM , ICD-10-CM Coding Guidelines when identifying diagnoses and procedures.
  5. Abstract information regarding congenital malformations for reporting to the Congenital Malformations Registry (CMR) as mandated by New York State.
  6. Utilize the Uniform Hospital Discharge Data Set Definitions (UHDDS) to select the principal diagnosis, principal procedure, and other relevant diagnoses and procedures.
  7. Utilize all available resources to assist coding and reimbursement to the facility, including the American Hospital Associations (AHA) Coding Clinic for ICD-9-CM, ICD-10-CM Faye Browns ICD-9-CM , ICD-10-CM Coding Handbook, electronic reference material available in 3M encoder, and institutional coding policies.
  8. Alert the Coding Compliance Managers when the medical record documentation requires further clarification.
  9. Use Webstrat encoder logic and grouper software to assign diagnosis and procedure codes and respective DRG. Utilize the clinical analyzer to assist in refining and focusing on reimbursement under the DRG payment system.
  10. Maintain and continually enhance and update coding skills and knowledge by participating in continuing education programs to support the effective application of ICD-9-CM, ICD-10-CM and coding guidelines to inpatient diagnoses and procedures. This is extremely important due to the fast pace of technological and clinical advances in the medical field and in retaining credentials.
  11. Abide by all Federal and state regulations, as dictated by CMS, Medicaid, and other third party payers regarding reimbursement for the facility.
  12. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).
  13. Maintain confidentiality of all patient records and medical and other information.


Qualifications

Requirements:
  • High School Diploma or GED
  • Certified Coding Specialist (CCS) credential required
  • Thorough knowledge of Medical Terminology, ICD-9-CM and ICD-10 coding, as well as DRG logic and CRT coding. Thorough knowledge of current coding guidelines.
  • Medical Records experience or related background
  • 2 or more years experience coding in a hospital setting preferred

Collective bargaining unit: OPEIU Local 153-MSB

OPEIU Local 153 at Mount Sinai Brooklyn, ACK - Medical Records - BKL, Mount Sinai Brooklyn

About Us

Strength Through Diversity

The Mount Sinai Health System believes that diversity, equity, and inclusion are key drivers for excellence. We share a common devotion to delivering exceptional patient care. When you join us, you become a part of Mount Sinai's unrivaled record of achievement, education, and advancement as we revolutionize medicine together. We invite you to participate actively as a part of the Mount Sinai Health System team by:
  • Using a lens of equity in all aspects of patient care delivery, education, and research to promote policies and practices to allow opportunities for all to thrive and reach their potential.
  • Serving as a role model confronting racist, sexist, or other inappropriate actions by speaking up, challenging exclusionary organizational practices, and standing side-by-side in support of colleagues who experience discrimination.
  • Inspiring and fostering an environment of anti-racist behaviors among and between departments and co-workers.

We work hard to acquire and retain the best people and to create an inclusive, welcoming and nurturing work environment where all feel they are valued, belong and are able to professional advance. We share the belief that all employees, regardless of job title or expertise contribute to the patient experience and quality of patient care.

Explore more about this opportunity and how you can help us write a new 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 43,000 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 approximately 7,400 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 and top 20 in Cardiology/Heart Surgery, 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. 14 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.

The Mount Sinai Health System is an equal opportunity employer. We comply with applicable Federal civil rights laws and does not discriminate, exclude, or treat people differently on the basis of race, color, national origin, age, religion, disability, sex, sexual orientation, gender identity, or gender expression. We are passionately committed to addressing racism and its effects on our faculty, staff, students, trainees, patients, visitors, and the communities we serve. Our goal is for Mount Sinai to become an anti-racist health care and learning institution that intentionally addresses structural racism."

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