Job Description

Medical Records Coder II - Full Time - Days at Mohawk Valley Health System summary:

The Medical Records Coder II is responsible for accurately assigning ICD-10-CM and PCS codes to patient records to ensure proper billing and compliance with healthcare regulations. This role involves analyzing medical documentation, resolving coding discrepancies, and collaborating with providers to improve data quality and revenue cycle operations. The position also includes mentoring new staff and supporting coding-related policy maintenance within a hospital setting.

Job Summary

Under the general direction of the Director CDI/Coding or designee, the Medical Records Coder I will improve documentation, data quality and revenue cycle operations. The coder assigns International Classification of Disease system- 10 (ICD), CM, and PCS codes according to AHA – AMA Guidelines, CMS and NGS.

Core Job Responsibilities

• Assign the appropriate DRG based on an analysis of the patient file and medical necessity
• Assign diagnosis and procedure codes, for accurate and timely billing of most appropriate payer
• Resolve diagnosis/procedure inconsistencies, concerns, and establish proper coding in collaboration with providers
• Initiate and follow up on queries with providers
• Abstract data elements and compile data for statistical reports
• Provide education based on recognized trends, including physician documentation
• Assist departments with diagnostic and procedural coding
• Respond to Insurance, compliance and RAC denials
• Review and assist in the maintenance of coding related policies and procedures
• Mentor new staff
• Perform other duties as required.

Education/Experience Requirements

REQUIRED:

• AS in Health Information Management, a related degree or equivalent experience
• RHIA, RHIT, CCS, CCA, CPC, CIC Certification 
• Knowledge of EMR, Coding software, and Microsoft Office
• Knowledge/understanding of Patient Safety Indicators (PSI), present on admission reporting requirements, and Hospital Acquired Conditions (HAC) and impact on quality and reimbursement
• Knowledge/understanding of SOI/ROM methodology
• Good Oral and Written Communication

PREFERRED:

• BS in Health Information Management
• Knowledge of Epic, 3M encoder, CDI Collaborate and Microsoft Office
• 2 years of hospital coding experience

Licensure/Certification Requirements

REQUIRED:

• RHIA, RHIT, CCS, CCA, CPC, CIC Certification or the ability to obtain

Disclaimer

Qualified applicants will receive consideration for employment without regard to their age, race, religion, national origin, ethnicity, age, gender (including pregnancy, childbirth, et al), sexual orientation, gender identity or expression, protected veteran status, or disability.

Successful candidates might be required to undergo a background verification with an external vendor

Job Details

Req Id 94951 
Department CODING 
Shift Days
Shift Hours Worked 7.50
FTE 0.94 
Work Schedule HRLY NON-UNION-8 HR
Employee Status A1 - Full-Time 
Union Non-Union
Pay Range $23 - $35/Hourly

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Keywords:

Medical coding, ICD-10-CM, PCS codes, Revenue cycle, Healthcare documentation, Coding compliance, Health Information Management, Medical records, Clinical documentation improvement, Hospital coding

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