Codes primarily acute hospital inpatient, SNF, and rehab records for accurate reimbursement, research, and compliance with federal regulations. Coding of ambulatory, ER/urgent care, interventional radiology, and same-day surgery records is performed as needed. Diagnoses and procedures are coded through review of the entire medical record using ICD-10-CM and CPT classifications. The role includes querying physicians for clarification when documentation is unclear, analyzing records for completeness, and actively participating as a member of the Clinical Documentation Improvement (CDI) team.
The position is primarily sedentary and office-based, with frequent keyboard use and work involving medical records, computers, software, and reference materials. Travel may be required for float positions and between facilities to assist with coding at other sites.
Education
- B.S. in Health Information Management or AAS in Health Information Technology
- RHIA or RHIT certification
- CCS preferred
- RHIA or RHIT-eligible candidates may be considered if enrolled in an HIT or HIM program and have completed coursework in coding, medical terminology, anatomy, and physiology
- Experienced coders with CCS credentials may also be considered
- Successful certification within one year of hire or graduation, whichever is later (AHIMA)
- Must pass a Catholic Health coding test
- Must maintain credentials through AHIMA continuing education requirements
- Participation in CDI team training, meetings, and activities
Experience
- Six months of coding experience in an acute care facility preferred
Knowledge and Skills
- Thorough knowledge of ICD-10-CM and CPT coding systems, medical terminology, anatomy, and physiology
- Ability to work collaboratively with associates, medical staff, department managers, CDI specialists, and finance
- Strong written and interpersonal communication skills
- Strong organization, prioritization, and deadline management skills
- Proficiency with computers, software, hardware, and technological advances
- Excellent analytical and problem-solving skills
- Ability to generate reports and work effectively with CDI worksheets
- Ability to read medical record documents and enter diagnoses, procedures, and patient data accurately throughout the day
- Ability to query physicians when appropriate based on documentation review
Location
Buffalo, New York, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
1 month ago