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/Knowledge:

High School Diploma 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.
Certification as an RHIA, RHIT, CCS and/or CCS-P, CPC and similar certification is preferred on hire. Required within one (1) year of employment.
Two (2) - five (5) years related experience. Experience in HIM preferred.

Department: Health Information Management Bargaining Unit:Non UnionCampus:TARRYTOWN Employment Status:Regular Full-TimeAddress:555 South Broadway, Tarrytown
Shift:DayScheduled Hours:8:30 AM-5 PMReq ID:216838Salary Range/Pay Rate:$73,202.07-$97,602.77

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

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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 ofdisability, 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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