Hospital Coder

Department/Unit:

Health Information Services

Work Shift:

Day (United States of America)

Salary Range:

Job Description Summary
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.

• 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.

Thank you for your interest in Albany Med Health System!​

Albany Med Health System is an equal opportunity employer.

This role may require access to information considered sensitive to Albany Med Health System, 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 Health System policies and standards, shall be made to ensure that information is adequately protected from unauthorized access and modification.