Coder Medical Record II

Reviews Emergency Department medical records and assigns accurate ICD-10-CM, CPT®, and HCPCS Level II codes for diagnoses, procedures, treatments, and services in accordance with Official Coding Guidelines, Medicare regulations, New York State requirements, and third-party payer policies. Ensures appropriate code assignment to support compliant reimbursement methodologies, including APC classification and outpatient payment systems.

Analyzes provider documentation to determine accurate code selection and identifies opportunities for documentation improvement. Queries physicians and other licensed practitioners when documentation is incomplete, conflicting, ambiguous, or insufficient to support accurate code assignment. Abstracts clinical and demographic data from the medical record and enters coded information into designated coding and billing systems.

Reviews coded encounters for accuracy, completeness, and compliance prior to final billing and claim submission. Monitors and validates data integrity within the billing system to ensure optimal reimbursement and regulatory compliance. Identifies cases requiring mandatory reporting, including reportable diseases, trauma registries, and other regulatory reporting requirements, as applicable.

Identifies potential cancer cases and other reportable conditions for referral to appropriate registries and reporting programs. Performs ongoing audits and quality reviews to ensure coding accuracy, consistency, and adherence to organizational standards. Reports coding, documentation, compliance, or reimbursement concerns to Coding Leadership and/or appropriate clinical staff for resolution.

Assists with coding-related audits, denials management, payer reviews, compliance investigations, and regulatory requests. Provides coding expertise and supports special projects, studies, quality initiatives, and data requests for leadership, committees, and regulatory agencies. Maintains current knowledge of coding regulations, reimbursement methodologies, documentation requirements, and industry best practices through continuing education and professional development activities.

Participates in departmental meetings, education sessions, and training programs to maintain competency and implement new coding guidelines and payer requirements. Reviews and monitors new clinical terminology, abbreviations, and documentation practices for compliance with organizational standards. Maintains strict confidentiality of patient, physician, and organizational information in accordance with HIPAA, organizational policies, and applicable privacy regulations.

Adheres to the AHIMA Code of Ethics , Standards of Ethical Coding, and all applicable compliance and regulatory requirements. Demonstrates flexibility to work varying schedules, shifts, overtime, or weekends as operational needs require. Performs other duties and responsibilities as assigned by Coding Leadership, HIM Management, or Department Administration.

Qualifications Associate degree in Health Information Management or related field preferred. Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Certified Coding Associate (CCA), or equivalent coding credential preferred. Minimum of 2 years of Emergency Department, outpatient, or facility coding experience preferred.

Thorough knowledge of ICD-10-CM, CPT®, HCPCS, APC methodology, Medicare regulations, and New York State reporting requirements. Strong analytical, problem-solving, communication, and organizational skills. Proficiency with electronic health records, encoder software, and computerized billing and abstracting systems.

Competencies Coding Accuracy and Compliance Clinical Documentation Review Regulatory Knowledge Revenue Cycle Awareness Critical Thinking and Decision-Making Attention to Detail Data Integrity and Quality Assurance Professional Ethics and Confidentiality Effective Communication and Physician Collaboration Shift - Mon, Wed, & Friday 8 am-1:50 pm Tues & Thurs 8 am-4:45 pm Hourly $39.5077 - $42.999