TH Medical Records Specialist
Stony Brook-University Hospital - New York, NY

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Descriptive Title: TH Medical Records Specialist
REF#: UH-S-5602-13-S(4)

Budget Title: Coding Specialist
State Professional Position

Department: Health Information Management
State Line#: 14308

Grade: SL-2
Campus: Stony Brook-University Hospital

Salary: Commensurate with experience
Required Qualifications: Associate degree in Health Information Management. In lieu of Associates degree, successful completion of a coding certificate in an AHIMA recognized program and two years additional applicable experience. RHIT, RHIA, CCS, certification. Minimum of two years of relevant acute care hospital medical record inpatient coding experience.
Preferred Qualifications:

Brief Description of Duties:
  • Abstracts pertinent information from patient records. Assigns ICD-9CM code, creating DRG group assignments.
  • Directly enters codes on the proper source documents and abstracts data.
  • Queries physicians when code assignments are not straight forward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
  • Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department manager for resolution.
  • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
  • Ensures the confidentiality of data contained in the medical records as outlined in institutional policies and procedures. Supports and promotes the HIM department by participating in special projects.

Special Notes: Shift: Full-time day position 8am-430pm. All Hospital positions are subject to changes in pass days and shifts as necessary. This position may require the wearing of respiratory protection which may prohibit the wearing of facial hair. Please note Stony Brook Medicine is a smoke free environment.

Please note: Prior to start date , the selected candidate must meet the following requirements: Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services, clear a background investigation; submit (3) written references, and provide a copy of the required license(s)/certificate(s). Please be advised that failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.

The selected candidate must successfully clear a background investigation.