Job Description

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 the provision of healthcare services). This position is responsible for selecting and sequencing the codes such that the organization receives the optimal reimbursement to which the facility is legally entitled, remembering that it is unethical and illegal to increase reimbursement by means that contradict requirements. Essential Duties and Responsibilities Use a computerized encoding system to facilitate accurate coding. Sequence diagnoses and procedures by following the ICD-10-CM/PCS, CPT4, Uniform Hospital Discharge Data Set (UHDDS), Medicare, Medicaid and other fiscal intermediary guidelines. Support the reporting of healthcare data elements (e.g. diagnoses and procedure codes, hospital acquired conditions, patient safety indicators) required for external reporting purposes (e.g. reimbursement, value based purchasing initiatives and other administrative uses, population health, quality and patient safety measurement, and research) completely and accurately, in accordance with regulatory and documentation standards and requirements, as well as all applicable official coding conventions, rules, and guidelines. Query the provider (physician or other qualified healthcare practitioner), whether verbal or written, for clarification and/or additional documentation when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element dependent on health record documentation (e.g. present on admission indicators). Advance coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities. Advances coding knowledge and practice through continuing education, including but not limited to meeting continuing education requirements. Utilizes official coding rules and guidelines apply the most accurate coding to represent that patient services on the hospital claim. Comply with comprehensive internal coding policies and procedures that are consistent with requirements. Attends coding meetings and roundtable sessions. Participates in daily huddles and LEAN problem-solving activities. Focused with no distractions while working and participating in meetings. Ensures camera on while attending Teams calls. Assists with organizing the shared drive for the medical coding department. Other duties as assigned by manager. Qualifications High School Diploma/G.E.D. - required Prior experience in hospital medical coding - preferred Prior experience with 3M 360 and EPIC system - preferred Applicants must receive a score of 80% or above on assessment. Will consider new coders with a higher assessment score. (High proficiency) Excellent computer skills, navigating multiple systems at once, troubleshooting. (High proficiency) Must be able to work independently as position is fully remote. Maintain a remote coding work area that protects confidential health information. (High proficiency) Excellent written and verbal communication skills. (High proficiency) Knowledge of ICD-10-CM, and ICD-10-PCS or CPT-4 Coding classification system, depending on the position being hired for. (High proficiency) Detail-oriented and efficient while maintaining productivity. Coding certification / credential through AHIMA or AAPC and be in good standing. - required Equivalent combination of relevant education and experience may be substituted as appropriate. This role may require access to information considered sensitive to Albany Medical Center, its patients, affiliates, and partners, including but not limited to HIPAA Protected Health Information and other information regulated by Federal and New York State statutes. Workforce members are expected to ensure that: Access to information is based on a “need to know” and is the minimum necessary to properly perform assigned duties. Use or disclosure shall not exceed the minimum amount of information needed to accomplish an intended purpose. Reasonable efforts, consistent with Albany Med Center policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.

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