Medical Records Specialist

2 weeks ago


New York, United States NYC Health + Hospitals Full time

**About NYC Health + Hospitals**:
Lincoln Medical and Mental Health Center is one of New York City’s premier acute care hospitals. Located in Downtown Bronx, Lincoln is a teaching hospital renowned for its Centers of Excellence, and a recognized industry leader in the implementation of state-of-the art medical technology and best practices. Our team of highly trained and caring medical professionals is dedicated to providing the highest quality health care that is safe, compassionate, culturally competent and patient-centered. Comprehensive services are offered in three major primary care areas: Medicine, Pediatrics, and Women’s Health in addition to more than eighty (80) specialty services. At Lincoln, the safety and comfort of our patients is our number one priority.

At NYC Health + Hospitals, our mission is to deliver high quality care health services, without exception. Every employee takes a person-centered approach that exemplifies the ICARE values (Integrity, Compassion, Accountability, Respect, and Excellence) through empathic communication and partnerships between all persons.

Medical Records Specialist under the supervision of the Associate Executive Director and/or Manager of the Revenue Initiatives Department is responsible for competently, accurately, and correctly assigning ICD-10CM diagnostic procedural codes, CPT, and HCPCS codes for the purpose of reimbursement, educational and statistical information.

**RESPONSIBILITIES/PROCEDURES**:
**With thorough knowledge of the duties to be performed**:

- Thoroughly reads and interprets the documentation contained in every medical record to identify all diagnoses and procedures to which codes must be affixed.
- Input coded information into 3M encoding system.
- Refers to Supervisor on issues with documentation. Supervisor will consult with the appropriate physician when conflicting or ambiguous information appears in the medical record, so the medical record documentation may be clarified.
- Applies Uniform Hospital Discharge Data Set definitions to select the principal diagnosis, principal procedure and other diagnoses and procedures, which require coding.
- Selects the appropriate principal diagnosis for episodes of care in which determination of the principal diagnosis is not clear-cut because the patient has multiple problems. Coder must refer to Clinical Coding Guidelines. In addition, coder must query provider
- Assesses the adequacy of documentation to ensure that it supports the principal diagnosis, principal procedure, complications and comorbidity conditions assigned codes.
- Applies sequencing guidelines so the chronology of patient care events can be understood by reviewing the assigned codes.
- Performs coding for Lincoln encounters
- Applies appropriate ICD10 Diagnostic Codes
- Applies appropriate CPT Procedure Codes
- Identify any discrepancy in documentation and escalate to supervisor
- Assist with clinical pertinence, chart analysis, and other HIM functions.
- Maintains LMMHC and HIM Safety Program, Quality Improvement Program, and In-Service Program.
- Assist with other related functions within the scope of the Medical Records Specialist.

**Minimum Qualifications**:
1. High School diploma or its educational equivalent; and
2. Completion of a coding, medical record technology or health information technology
program approved by the American Health Information Management Association
(AHIMA); or
3. Possession of a valid certificate as a Certified Coding Specialist (CCS) from the
American Health Information Management Association (AHIMA); or
4. Two (2) years of satisfactory experience in coding and abstracting medical records in a
recognized hospital or health care organization.

**How To Apply**:
Lincoln Medical & Mental Health Center
Human Resources Department
234 Eugenio Maria De Hostos Blvd, (East 149th Street),
2nd Floor, Annex
Bronx, NY 10451
Attn: Recruitment Unit

NYC Health and Hospitals offers a competitive benefits package that includes:

- Comprehensive Health Benefits for employees hired to work 20+ hrs. per week
- Retirement Savings and Pension Plans
- Loan Forgiveness Programs for eligible employees
- Paid Holidays and Vacation in accordance with employees' Collectively bargained contracts
- College tuition discounts and professional development opportunities
- Multiple employee discounts programs



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