The Department of Health Information Management at SUNY Downstate Health Sciences University is seeking a full-time Medical Records Specialist / Outpatient Coding Specialist.
The Outpatient Coding Specialist reviews, analyzes, and accurately codes outpatient medical records in accordance with established coding guidelines, regulatory requirements, and institutional policies. This role abstracts relevant clinical information and assigns diagnosis and procedure codes to support accurate documentation, coding compliance, and appropriate reimbursement for outpatient services.
The position collaborates with physicians, clinical departments, and Health Information Management staff to resolve documentation deficiencies, maintain coding accuracy, and support the institution's health information and revenue cycle processes.
Key responsibilities
- Review outpatient medical records and abstract clinical information for accurate code assignment.
- Assign ICD-10-CM, CPT, and applicable HCPCS Level II codes according to official guidelines.
- Ensure coding accuracy, consistency, compliance, and appropriate sequencing of diagnoses and procedures.
- Review documentation for completeness and support appropriate reimbursement.
- Query physicians when documentation is incomplete, conflicting, or unclear.
- Identify coding discrepancies and compliance concerns and escalate as needed.
- Collaborate with physicians, clinical staff, and HIM personnel to resolve coding issues.
- Use electronic health records and coding applications to maintain accurate coding records.
- Maintain standards for productivity, turnaround time, and quality.
- Participate in coding audits, quality assurance activities, staff education, and process improvement initiatives.
Required qualifications
- High school diploma or equivalent.
- At least 1 year of direct professional medical coding experience in a hospital or outpatient healthcare setting.
- Current certification in at least one of the following:
- RHIA
- RHIT
- CCS
- CPC
- Knowledge of ICD-10-CM, CPT, and applicable HCPCS Level II coding systems.
- Knowledge of medical terminology, anatomy and physiology, and outpatient clinical documentation.
- Ability to review medical records, abstract clinical information, and independently assign diagnosis and procedure codes.
- Understanding of coding compliance standards, documentation requirements, and patient confidentiality regulations.
- Strong analytical, organizational, and attention-to-detail skills.
- Effective written and verbal communication skills.
Preferred qualifications
- Bachelor's degree in Health Information Management, Health Information Technology, Health Sciences, or a related field.
- 3 to 5 years of medical coding experience in an acute care hospital or hospital-based outpatient setting.
- Experience coding outpatient hospital services such as ambulatory surgery, emergency department, and outpatient procedures.
- Experience with electronic health record systems, computerized coding applications, and coding reference tools.
- Familiarity with outpatient reimbursement methodologies, coding edits, payer requirements, and coding compliance audits.
- Experience collaborating with physicians and clinical departments to improve coding accuracy.
Location
New York, US
Employment Type
Full-time
Experience Level
Entry Level
Remote work allowed
No
Posted
3 weeks ago