Introduction
To heal, to teach, to discover and to advance the health of the communities we serve.
To learn more about the “Montefiore Difference” – who we are at Montefiore and all that we have to offer our associates, please click here.
Overview
Under general direction reviews and researches patient medical records in order to describe reason for admission/visit/care, treatment rendered \, surgical procedures performed and diagnoses at discharge. Identifies and documents reason for care, sequence of events, therapies, procedures and diagnoses by applying appropriate codes from diseases and procedure coding classifications such as ICD-10 CM, PCS, CPT- 4, etc., and using associated guidelines and rules for the level and type of care received by the patient.
Responsibilities
In coordination with physician, nursing and other clinical staff, ensures that data is complete and that the codes applied accurately describe patient status during hospitalization /visit and that they support appropriate grouping methodologies for optimal reimbursement, reporting and compliance with Federal, State and commercial insurance requirements. Abstracts pertinent clinical data from the record and enters into appropriate data repository for use in billing, research, registries, billing, education, planning, performance improvement and reporting.
Requirements
- High School Diploma or GED required
- Associates Degree preferred
- Two (2) of relevant, progressive experience required. Experience in HIM a plus.
- Candidates must know coding techniques and be familiar with reviewing medical records in an electronic environment.
- Candidates for this position must have satisfactory completion of an industry recognized curriculum in Coding using ICD -10CM, ICD-10 PCS/CPT4
- Candidates must be experienced reviewing and abstracting records for patients in all levels of care in a complex health care environment such as Montefiore.
- Candidates must obtain certified credentials within 2 years of employment if not yet completed at the time of hire.
- Successful completion of AHIMA recognized Course in Coding with Certification as an RHIA, RHIT, CCS and/or CCS-P, CPC and similar certification required within two (2) years of employment. Preferred on hire.
- Satisfactory combination of education, knowledge and experience in a health care environment applying coding classifications and grouping methodologies.
