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Full/Part Time: Full Time
Location/Affiliates: Mount Sinai Medical Center (Manhattan)
Department: 183 - Medical Records
Requisition Number: 13-1583640
The Coding Trainee will obtain coding practice experience in applying coding principles and guidelines to review electronic clinical documentation, extract diagnoses and procedures, and accurately assign ICD-9-CM codes.
Duties and Responsibilities:
1. Learn and apply learning to thoroughly review and evaluate the entire electronic medical record documentation, including physician progress notes, consultations and orders, operative reports, laboratory, pathology, radiology and other ancillary reports, nursing notes and medication administration records, and discharge summaries.
2. Apply knowledge of anatomy and physiology, disease process and pharmacology to identify diagnoses and procedures based on medical record documentation.
3. Apply knowledge of ICD-9-CM coding guidelines and Uniform Hospital Discharge Data Set Definitions (UHDDS) to abstract and sequence all reportable diagnosis and procedures.
4. Apply knowledge of ICD-9-CM coding guidelines and conventions to assign diagnostic and procedure codes.
5. Learn and apply learning to use 3M encoder logic and grouper software to assign diagnosis and procedure codes and DRGs.
6. Apply knowledge of Present on Admission (POA) reporting guidelines.
7. Learn and apply learning to ensure that physician documentation supports coding.
8. Maintain daily log and abstract forms of records coded.
9. Review instructor feedback on coded records to enhance learning and progressively increase coding knowledge.
10. Achieve and maintain coding accuracy standard of 95%.
11. Progressively increase and maintain production standards throughout the apprenticeship.
12. Achieve a productivity standard of 18 records daily by the end of the apprenticeship.
13. Abide by the Standards of Ethical Coding set forth by the American Health Information Management Association (AHIMA)
14. Maintain confidentiality of all patient records and protected health information.
15. Performs other related duties.
High School or GED required
Medical Coding Certificate from a qualified program required
Completion of 1199-sponsored coding refresher class required.
Associae's degree and/or College science courses in Anatomy and Physiology preferred
3-5 years of working in a Medical Records department or in health care related field.
Review or analysis of medical records or any experience coding medical records
* Ability to work independently and set priorities
* Ability to concentrated for long period of time
Mount Sinai Medical Center is an equal opportunity/affirmative action employer. We recognize the power and importance of a diverse employee population and strongly encourage applicants with various experiences and backgrounds. Mount Sinai Medical Center--An EEO/AA-D/V Employer.