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Job Description

Responsible for coding and analysis of complex inpatient medical records, utilizing ICD-9-CM (International Classification of Diseases, 9th Revision, Clinical Modification)ICD-10-CM (International Classification of Diseases 10th revision) coding guidelines and conventions for establishment of diagnosis and procedures. The coded information is utilized for reimbursement purposes, data retrieval, education, to support medical research activity, assessment of clinical care, evaluation of medical services, case mix for the facility, and identification of health care concerns for public health.

Qualifications

_Requirements:_

+ High School Diploma or GED

+ Certified Coding Specialist (CCS) credential required

+ Thorough knowledge of Medical Terminology, ICD-9-CM and ICD-10 coding, as well as DRG logic and CRT coding. Thorough knowledge of current coding guidelines.

+ Medical Records experience or related background

+ 2 or more years experience coding in a hospital setting preferred

Collective bargaining unit: OPEIU Local 153-MSB

OPEIU Local 153 at Mount Sinai Brooklyn, ACK - Medical Records - BKL, Mount Sinai Brooklyn

Responsibilities

Medical Records – InPatient Coder - THIS IS AN ON-SITE POSITION

1. Thoroughly review, analyze, and interpret the entire medical record (electronic and hardcopy), including progress notes, consultation reports, physician orders, nursing notes, operative reports, pathology reports, radiology reports, laboratory results, medication records, other ancillary service reports, and the discharge summary to identify all diagnoses and procedures occurring/affecting the current admission.

2. Apply knowledge of anatomy and physiology, disease process, pharmacology, to identify diagnoses and procedures documented in the medical record.

3. Apply knowledge of the ICD-9-CM, ICD-10-CM coding system to translate identified diagnoses and procedures to codes for accurate reimbursement and data.

4. Adhere to Official ICD-9-CM , ICD-10-CM Coding Guidelines when identifying diagnoses and procedures.

5. Abstract information regarding congenital malformations for reporting to the Congenital Malformations Registry (CMR) as mandated by New York State.

6. Utilize the Uniform Hospital Discharge Data Set Definitions (UHDDS) to select the principal diagnosis, principal procedure, and other relevant diagnoses and procedures.

7. Utilize all available resources to assist coding and reimbursement to the facility, including the American Hospital Associations (AHA) Coding Clinic for ICD-9-CM, ICD-10-CM Faye Browns ICD-9-CM , ICD-10-CM Coding Handbook, electronic reference material available in 3M encoder, and institutional coding policies.

8. Alert the Coding Compliance Managers when the medical record documentation requires further clarification.

9. Use Webstrat encoder logic and grouper software to assign diagnosis and procedure codes and respective DRG. Utilize the clinical analyzer to assist in refining and focusing on reimbursement under the DRG payment system.

10. Maintain and continually enhance and update coding skills and knowledge by participating in continuing education programs to support the effective application of ICD-9-CM, ICD-10-CM and coding guidelines to inpatient diagnoses and procedures. This is extremely important due to the fast pace of technological and clinical advances in the medical field and in retaining credentials.

11. Abide by all Federal and state regulations, as dictated by CMS, Medicaid, and other third party payers regarding reimbursement for the facility.

12. Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).

13. Maintain confidentiality of all patient records and medical and other information.

About Us

Strength through Unity and Inclusion

The Mount Sinai Health System is committed to fostering an environment where everyone can contribute to excellence. We share a common dedication to delivering outstanding patient care. When you join us, you become part of Mount Sinai’s unparalleled legacy of achievement, education, and innovation as we work together to transform healthcare. We encourage all team members to actively participate in creating a culture that ensures fair access to opportunities, promotes inclusive practices, and supports the success of every individual.

At Mount Sinai, our leaders are committed to fostering a workplace where all employees feel valued, respected, and empowered to grow. We strive to create an environment where collaboration, fairness, and continuous learning drive positive change, improving the well-being of our staff, patients, and organization. Our leaders are expected to challenge outdated practices, promote a culture of respect, and work toward meaningful improvements that enhance patient care and workplace experiences. We are dedicated to building a supportive and welcoming environment where everyone has the opportunity to thrive and advance professionally. Explore this opportunity and be part of the next chapter in our history.

About the Mount Sinai Health System:

Mount Sinai Health System is one of the largest academic medical systems in the New York metro area, with more than 48,000 employees working across eight hospitals, more than 400 outpatient practices, more than 300 labs, a school of nursing, and a leading school of medicine and graduate education. Mount Sinai advances health for all people, everywhere, by taking on the most complex health care challenges of our time — discovering and applying new scientific learning and knowledge; developing safer, more effective treatments; educating the next generation of medical leaders and innovators; and supporting local communities by delivering high-quality care to all who need it. Through the integration of its hospitals, labs, and schools, Mount Sinai offers comprehensive health care solutions from birth through geriatrics, leveraging innovative approaches such as artificial intelligence and informatics while keeping patients’ medical and emotional needs at the center of all treatment. The Health System includes more than 9,000 primary and specialty care physicians; 13 joint-venture outpatient surgery centers throughout the five boroughs of New York City, Westchester, Long Island, and Florida; and more than 30 affiliated community health centers. We are consistently ranked by U.S. News & World Report's Best Hospitals, receiving high "Honor Roll" status, and are highly ranked: No. 1 in Geriatrics, top 5 in Cardiology/Heart Surgery, and top 20 in Diabetes/Endocrinology, Gastroenterology/GI Surgery, Neurology/Neurosurgery, Orthopedics, Pulmonology/Lung Surgery, Rehabilitation, and Urology. New York Eye and Ear Infirmary of Mount Sinai is ranked No. 12 in Ophthalmology. U.S. News & World Report’s “Best Children’s Hospitals” ranks Mount Sinai Kravis Children's Hospital among the country’s best in several pediatric specialties. The Icahn School of Medicine at Mount Sinai is ranked No. 11 nationwide in National Institutes of Health funding and in the 99th percentile in research dollars per investigator according to the Association of American Medical Colleges. Newsweek’s “The World’s Best Smart Hospitals” ranks The Mount Sinai Hospital as No. 1 in New York and in the top five globally, and Mount Sinai Morningside in the top 20 globally.

Equal Opportunity Employer

The Mount Sinai Health System is an equal opportunity employer, complying with all applicable federal civil rights laws. We do not discriminate, exclude, or treat individuals differently based on race, color, national origin, age, religion, disability, sex, sexual orientation, gender, veteran status, or any other characteristic protected by law. We are deeply committed to fostering an environment where all faculty, staff, students, trainees, patients, visitors, and the communities we serve feel respected and supported. Our goal is to create a healthcare and learning institution that actively works to remove barriers, address challenges, and promote fairness in all aspects of our organization.

Compensation Statement

Mount Sinai Health System (MSHS) provides a salary range to comply with the New York City Law on Salary Transparency in Job Advertisements. The salary range for the role is $42.8186 - $42.8186 Hourly. Actual salaries depend on a variety of factors, including experience, education, and hospital need. The salary range or contractual rate listed does not include bonuses/incentive, differential pay or other forms of compensation or benefits.