Certified Medical Records Coder - On Site - 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. The selected candidate will work on site in Greenport, NY for all shifts. 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. Ensures all open queries have been addressed, collaborating with Clinical Documentation Specialists prior to final coding. Adheres to department standards for productivity and accuracy. Identifies and trends coding issues and escalates 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 (e.g., 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 Good vision and hearing. Operate typewriter or computer keyboard, answer phones, open file drawers. Must be able to communicate orally. Anticipated Pay Range $33.766-$36.104 per hour. Pre‑Employment 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 professional references. Successfully complete a 4‑panel drug screen. Meet regulatory requirements for pre‑employment screenings. Provide a copy of any required NewYork State license(s)/certificate(s). Equal Employment Opportunity 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. #J-18808-Ljbffr