Coder/Abstractor-Outpatient Level II
: Job Details :

Position Summary:Codes and abstracts medical records according to established guidelines; performs limited discharge analysis. Must perform charge validating and correction, append modifiers appropriately on all HCPC/CPT codes, communication with other departments, and be able to work with spreadsheets. Must be able to work independently.Essential Functions and Responsibilities Includes the Following:1. Understands and adheres to the WPH Performance Standards, Policies and Behaviors2. Accurately applies ICD-10 CM, ICD- 10 PCS, CPT-4, and HCPCS established coding guidelines when assigning codes3. Must be able to navigate local coverage determinations (LCD) alerts to ensure records are compliant.4. Seeks clarification on information needed to assign accurate and specific codes and alerts physician when additional supporting documentation is needed5. Meets established quality standards for coding and abstracting of medical records6. Meets established productivity standards and completes work within required time frames7. Demonstrates the ability to use Microsoft applications, and HIM software applications including 3M, 3M 360 coding applications.8. Attends staff meetings as required to update knowledge related to current department/hospital issues/status9. Attends educational meetings as requested/required to update knowledge related to coding/compliance10. Completes annual department/hospital competency requirements.11. Performs all other related duties as assignedEducation & Experience RequirementsHigh School or GED required. College degree preferred.Minimum of two year of coding experience in a Health Information Management Department preferred.Certified Coding Specialist (CCS) and/or RHIT preferred; knowledge of ICD-10-CM, HCPCS and CPT-4 coding, medical terminology, anatomy and physiology required.Core Competencies1. Must be detail oriented and accurate.2. Must be able to work under pressure with time constraints.3. Must interact in a pleasant and professional manner with all internal and external customers and employees;4. Demonstrates the ability to discuss technical issues involving clinical data with Medical Staff and Nursing Staff.5. Must be able to speak, write, and understand the English language; must be able to converse on a clinical level with medical staff in order to perform required dutiesPhysical/Mental Demands/Requirements & Work Environment• May be exposed to chemicals necessary to perform required tasks. Any hazardous chemicals the employee may be exposed to are listed in the hospital's SDS (Safety Data Sheet) data base and may be accessed through the hospital's Intranet site (Employee Tools/SDS Access). A copy of the SDS data base can also be found at the hospital switchboard, saved on a disc.• Must be able to retain focused concentration despite distractions; must be flexible and able to adapt to changes in routines and procedures• Must be a team player; must be able to retain composure under stress• Ability to remain stationary for extended periods of time• The role routinely uses standard office equipment such as phones, computers, photocopiers, filing cabinets and fax machines located at multiple locations within the building.• Trouble shoot computer system and equipmentPrimary Population ServedCheck appropriate box(s) below:• Non-patient care populationThe responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of White Plains Hospital.