Overview The Junior Coder is responsible for coding medical records, including all diagnoses and operative and diagnostic procedures in patient medical records, using the current ICD10 CM/PCS, CPT and HCPCS coding systems and entering coded information into an automated grouper system. Duties include coding, data abstraction, and supporting various medical records functions. Responsibilities Using the current HCPCS, ICD10 CM/PCS and CPT coding systems, assign and record accurate codes to all diagnoses, procedures, and operations as documented by the attending physician in the patient's medical record. Ensure all factors necessary for assigning an accurate DRG are present and diagnoses are ranked properly. Obtain necessary information by contacting appropriate providers to clarify documentation as needed. Enter final diagnostic codes and narrative descriptions of diagnoses and procedures into an automated grouper system. Abstract information from medical records to compile reports and statistical information. Enter data such as diagnosis, treatment, admission and discharge dates, and length of stay into hospital-wide or regional automated databases. Participate in other medical records functions as assigned; query appropriate providers regarding documentation of diagnoses and procedures. Tracker management: coding queries and denials; perform other duties as assigned. Qualifications/Requirements Education High school or equivalency diploma required. An Associate's or Bachelor's degree in health information management is preferred. Experience / Credentials Option A: CPC, CPC-A, COC, CCS or CCS-P credential; or Option B: 1-2 years of experience with medical records in a health care setting; or Option C: completion of at least 30 college credits with coursework in medical terminology and ICD coding or at least six credits in anatomy and physiology; or Option D: completion of a college certificate program in medical records coding (at least 30 credits); or Option E: equivalent combination including specialized coursework in medical terminology and ICD coding or anatomy/physiology credits. Licenses / Certifications CPC, CPC-A, COC, CCS or CCS-P credential preferred. Knowledge, Skills and Abilities Good knowledge of medical terminology; working knowledge of medical record systems and operation; working knowledge of current HCPCS, CPT and ICD10 CM/PCS codes. Ability to understand and code medical records; strong communication skills; computer literacy (spreadsheets, word processing, calendar, e-mail); ability to read, write, speak, understand, and communicate effectively to perform essential duties. Other Seniority level: Entry level Employment type: Full-time Job function: Engineering and Information Technology Industries: Hospitals and Health Care #J-18808-Ljbffr Westchester Medical Center Health Network
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