Certified Medical Records Coder - Per Diem - Eastern Long Island Hospital

Position Summary: In this role, the successful candidate analyzes medical records, extracts clinical, pathological, therapeutic and epidemiologic data for Inpatient and/or Outpatient records in accordance with established ICD-10-CM/PCS and CPT coding principles and guidelines. Health Information Coders analyze, abstract, and code in order for the hospital to submit a bill for services rendered and various departments and clinics associated with patient care; perform other related duties as required. Medical coding is a critical aspect of HIM. Professionals assign standardized codes to diagnoses and procedures, which are used for billing, insurance claims, and statistical analysis. They use coding systems such as ICD-10 (International Classification of Diseases) and CPT (Current Procedural Terminology).

Job Duties & Essential Functions

• Abstracts and codes medical information from Inpatient and/or Outpatient charts into the organization billing/abstracting systems to complete the coding function through established best practice processes and professional regulatory coding guidelines, policies and procedures.
• Ensures that each diagnosis present on admission (POA) indicator is assigned appropriately.
• Adheres to coding compliance policies and procedures for assignment of complete, accurate, timely and consistent codes.
• Identify and request physician queries following established guidelines when existing documentation is unclear or ambiguous following appropriate standards and guidelines and established organization.
• Ensures all open queries have been addressed, collaborating with Clinical Documentation Specialist when necessary, prior to final coding.
• Adheres to department standards for productivity and accuracy.
• Identifies and trends coding issues and escalating identified concerns to Department Director.
• Participates in on site, remote and/or external training workshops and training. Demonstrates proficiency in utilizing official coding books as well as the electronic medical record.
• Consults, provides professional expertise to and collaborates with clinical documentation specialists on coding and documentation practices and standards.
• Maintains active and up-to-date coding certification by meeting continuing education requirements.
• Performs other duties as assigned.

Required Experience & Qualifications

• Coding Certification (ie. CCS, CCA, CPC).
• Knowledge of electronic medical records and 3M or Encoder System.
• Strong knowledge of medical terminology and basic anatomy and physiology, pathophysiology, and pharmacology with the ability to apply this knowledge to the coding process.
• Knowledge of MS DRG prospective payment system and severity systems.
• Ability to concentrate for extended periods of time.
• Ability to work and make decisions independently.

Preferred Experience & Qualifications

• Electronic Medical Record system experience.
• Hospital-based coding experience.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

• Good vision and hearing.
• Operate typewriter or computer keyboard, answer phones, open file drawers.
• Must be able to communicate orally.

The responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of SBELIH.

Special Notes : Resume/CV should be included with the online application.

• Stony Brook Medicine is a smoke-free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
• All Hospital positions may be subject to changes in pass days and shifts as necessary.
• This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
• This function/position maybe designated as “essential.” This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook Eastern Long Island and related facilities.

Anticipated Pay Range:

The starting salary range (or hiring range) for this position has been established based on relevant experience. The above salary range (or hiring range) represents SBEILH’s good faith and reasonable estimate of the range of possible compensation at the time of posting.

Your total compensation goes beyond the number in your paycheck!

Prior to start date, the selected candidate must meet the following requirements:

• Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Eastern Long Island’s Employee Health Services *
• Complete electronic reference check with a minimum of three (3) professional references.
• Successfully complete a 4 panel drug screen*
• Meet Regulatory Requirements for pre-employment screenings.
• Provide a copy of any required New York State license(s)/certificate(s).

Failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.

*The Human Resources department will be responsible for any fee incurred for examination.

Company Overview:

As part of Stony Brook Medicine, Stony Brook Eastern Long Island Hospital (SBELIH) combines the best in academic and community medicine, improving access to advanced medical care for residents of the North Fork and Shelter Island. With 70 beds, SBELIH is Suffolk County’s first hospital, serving the North Fork since 1905. SBELIH provides care to 25,000 year-round residents and expanding to 60,000 summer residents with comprehensive healthcare solutions, including behavioral health, medical-surgical, orthopedics and general surgery, wound care, interventional pain management and GI, advanced ambulatory care, diagnostic, and physical therapy services. The hospital is also a clinical campus and training site for Stony Brook Medicine, with its first SBELIH Psychiatry resident having graduated in 2022.

StaffCo is a Professional Employer Organization, commonly referred to as a PEO, duly organized and registered under the New York Professional Employer Organization law. StaffCo and SUNY have entered into a professional employer agreement under which StaffCo is the employer of Stony Brook Eastern Long Island employees and responsible for all aspects of employment, including hirings, promotions, disciplines, terminations, the day-to-day direction and supervision of work, as well as labor relations and collective bargaining. StaffCo is fully responsible for providing all payroll and human resources services, including the payment of wages, collecting and reporting payroll taxes and maintaining any and all employee benefits. SUNY Stony Brook Hospital is responsible for the operation of the hospital and provision of health care and is the co-employer as is necessary to conduct its responsibilities and for related licensure, regulatory or statutory requirements and obligations.

Given StaffCo’s employment responsibilities, it is deemed the “employer” for employment and labor law purposes. Thus, the employees are private sector employees of StaffCo, not public sector employees of SUNY. The private sector nature of the StaffCo employees has been approved by NYS Civil Service and upheld in a decision by the US National Labor Relations Board.

Stony Brook Medicine is committed to excellence in diversity and the creation of an inclusive learning, and working environment. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, sex, pregnancy, familial status, sexual orientation, gender identity or expression, age, disability, genetic information, veteran status and all other protected classes under federal or state laws.

Stony Brook Eastern Long Island Hospital, consistent with our shared core values and our intent to achieve excellence, remains dedicated to supporting healthier and more resilient communities, both locally and globally.