The Hospital Coder applies skills and knowledge of currently mandated coding and classification systems, and official resources to select the appropriate diagnostic and procedural codes (including applicable modifiers), and other codes representing healthcare services (including substances, equipment, supplies, or other items used in healthcare provision). This role ensures the organization receives optimal and legal reimbursement by selecting and sequencing codes accurately.

Responsibilities include:

Use computerized encoding systems to code and sequence diagnoses and procedures per ICD-10-CM/PCS, CPT4, UHDDS, Medicare, Medicaid, and other guidelines.
Support reporting of healthcare data elements required for external purposes such as reimbursement, value-based purchasing, population health, quality and patient safety measurement, and research, adhering to regulatory and documentation standards.
Query providers for clarification or additional documentation when health record information is conflicting, incomplete, or ambiguous regarding significant reportable conditions or procedures.
Demonstrate integrity, ethical and legal coding practices, and foster professional trust.
Participate in continuing education to advance coding knowledge and maintain certification requirements.
Apply official coding rules to ensure accurate representation of patient services on hospital claims.
Comply with internal coding policies consistent with external requirements.
Attend coding meetings, roundtables, daily huddles, and LEAN problem-solving activities.
Maintain focus during work and meetings; ensure video is on during Teams calls.
Assist in organizing the shared medical coding department drive.
Perform other assigned duties as directed by management.

Qualifications:

High school diploma or GED required.
Preferred prior hospital medical coding experience.
Preferred experience with 3M 360 and EPIC systems.
Must score 80% or above on assessment; higher scores considered for new coders.
High proficiency in computer skills, multitasking across systems, troubleshooting.
Ability to work independently in a fully remote environment maintaining confidentiality.
Excellent written and verbal communication skills.
Knowledge of ICD-10-CM, ICD-10-PCS, and CPT-4 coding classification systems.
Detail-oriented with efficient productivity.
Required coding certification/credential through AHIMA or AAPC, in good standing.
Equivalent education and experience combinations considered as appropriate.

Albany Med Health System is an equal opportunity employer committed to protecting sensitive information in accordance with HIPAA and applicable federal and state laws.