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.

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.

EDUCATION/SKILLS/KNOWLEDGE:

High School Diploma/GED required.

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 have a combination of education, knowledge and experience in a health care environment applying coding classifications and grouping methodologies such as DRGs.

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 be obtain certified credentials within 1 year of employment if not yet completed at the time of hire.

Two (2) - five (5) years related experience. Experience in HIM preferred.

Department: Health Information Management Bargaining Unit: Non Union Campus: TARRYTOWN Employment Status: Regular Full-Time Address: 555 South Broadway, Tarrytown

Shift: Day Scheduled Hours: 8:30 AM-5 PM Req ID: 218480 Salary Range/Pay Rate: $73,202.07 - $97,602.77

For positions that have only a rate listed, the displayed rate is the hiring rate but could be subject to change based on shift differential, experience, education or other relevant factors.

To learn more about the "Montefiore Difference" - who we are at Montefiore and all that we have to offer our associates, please click here.

Diversity, equity and inclusion are core values of Montefiore. We are committed to recruiting and creating an environment in which associates feel empowered to thrive and be their authentic selves through our inclusive culture. We welcome your interest and invite you to join us.

Montefiore is an equal employment opportunity employer. Montefiore will recruit, hire, train, transfer, promote, layoff and discharge associates in all job classifications without regard to their race, color, religion, creed, national origin, alienage or citizenship status, age, gender, actual or presumed disability, history of disability, sexual orientation, gender identity, gender expression, genetic predisposition or carrier status, pregnancy, military status, marital status, or partnership status, or any other characteristic protected by law.

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