Coder Level 2

Job Description

Strength Through Diversity

Ground breaking science. Advancing medicine. Healing made personal.

Roles & Responsibilities:
  • Responsible for coding and analysis of complex inpatient medical records, utilizing ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification) ICD-10-CM (International Classification of Diseases 10th revision)  coding guidelines and conventions for establishment of diagnosis and procedures. The coded information is utilized for reimbursement purposes, data retrieval, education, to support medical research activity, assessment of clinical care, evaluation of medical services, case mix for the facility, and identification of health care concerns for public health.


    Essential Duties and Responsibilities                                                                                             

    1. Thoroughly review, analyze, and interpret the entire medical record (electronic and hardcopy), including progress notes, consultation reports, physician orders, nursing notes,  operative reports, pathology reports, radiology reports, laboratory results, medication records, other ancillary service reports, and the discharge summary to identify all diagnoses and procedures occurring/affecting the current admission.
    2. Apply knowledge of anatomy and physiology, disease process, pharmacology, to identify diagnoses and procedures documented in the medical record.
    3. Apply knowledge of the ICD-9-CM, ICD-10-CM coding system to translate identified diagnoses and procedures to codes for accurate reimbursement and data.
    4. Adhere to Official ICD-9-CM , ICD-10-CM Coding Guidelines when identifying diagnoses and procedures.
    5. Abstract information regarding congenital malformations for reporting to the Congenital Malformations Registry (CMR) as mandated by New York State.
    6. Utilize the Uniform Hospital Discharge Data Set Definitions (UHDDS) to select the principal diagnosis, principal procedure, and other relevant diagnoses and procedures.
    7. Utilize all available resources to assist coding and reimbursement to the facility, including the American Hospital Association’s (AHA) Coding Clinic for ICD-9-CM & ICD-10-CM, Faye Brown’s ICD-9-CM & ICD-10-CM Coding Handbook, electronic reference material available in 3M encoder, and institutional coding policies.
    8. Alert the Coding Compliance Managers when the medical record documentation requires further clarification.
    9. Use Webstrat encoder logic and grouper software to assign diagnosis and procedure codes and respective DRG. Utilize the clinical analyzer to assist in refining and focusing on reimbursement under the DRG payment system.
    10. Maintain and continually enhance and update coding skills and knowledge by participating in continuing education programs to support the effective application of ICD-9-CM, ICD-10-CM  and coding guidelines to inpatient diagnoses and procedures. This is extremely important due to the fast pace of technological and clinical advances in the medical field and in retaining credentials.
    11. Abide by all Federal and state regulations,  as dictated by CMS, Medicaid, and other third party payers regarding reimbursement for the facility.
    12. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).
    13. Maintain confidentiality of all patient records and medical and other information.


    Education Requirements                                                                                                                 

    High School education, associate degree preferred


    Experience Requirements                                                                                                                 

    Minimum 2 - 5 years inpatient coding experience in acute care hospital

    Proficiency in the use of computers 3M or Optum Webstrat knowledge or other encoding system.


    Licensing and Certification Requirements                                                                                   

    CCS or CPC required with completion of ICD-10-CM and PCS training transcript or certificate of completion.


Strength Through Diversity

The Mount Sinai Health System believes that diversity and inclusion is a driver for excellence. We share a common devotion to delivering exceptional patient care. Yet we’re as diverse as the city we call home- culturally, ethically, in outlook and lifestyle. When you join us, you become a part of Mount Sinai’s unrivaled record of achievement, education and advancement as we revolutionize healthcare delivery together.
We work hard to recruit and retain the best people, and to create a welcoming, nurturing work environment where you have the opportunity and support to develop professionally. We share the belief that all employees, regardless of job title or expertise, have an impact on quality patient care. 

Explore more about this opportunity and how you can help us write a new chapter in our story! 

Who We Are

Over 38,000 employees strong, the mission of the Mount Sinai Health System is to provide compassionate patient care with seamless coordination and to advance medicine through unrivaled education, research, and outreach in the many diverse communities we serve.
Formed in September 2013, The Mount Sinai Health System combines the excellence of the Icahn School of Medicine at Mount Sinai with seven premier hospitals, including Mount Sinai Beth Israel, Mount Sinai Brooklyn, The Mount Sinai Hospital, Mount Sinai Queens, Mount Sinai West (formerly Mount Sinai Roosevelt), Mount Sinai St. Luke’s, and New York Eye and Ear Infirmary of Mount Sinai.
The Mount Sinai Health System is an equal opportunity employer. We promote recognition and respect for individual and cultural differences, and we work to make our employees feel valued and appreciated, whatever their race, gender, background, or sexual orientation. 

EOE Minorities/Women/Disabled/Veterans


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