Hospital Inpatient Coder, Certified

Job Description:

  • Reviews complete inpatient medical records, including physician notes, operative reports, consultations, imaging, lab results, and discharge summaries
  • Assigns and properly sequences accurate ICD-10-CM diagnosis and ICD-10-PCS procedure codes in accordance with Official Coding Guidelines, UHDDS definitions, Coding Clinic guidance, and CMS to a full range of inpatient services including cases with a high complexity level
  • Assigns correct and optimal DRGs (MS-DRG/APR-DRG)
  • Ensures accurate capture of Major Comorbid Conditions (MCC)/Comorbid Conditions (CC), Present on Admission (POA) indicators, Hospital-Acquired Conditions (HACs), Patient Safety Indicators (PSIs), Severity of Illness (SOI), and Risk of Mortality (ROM)
  • Issues compliant physician queries when documentation is incomplete, ambiguous, or inconsistent
  • Identifies documentation gaps and escalates when clarification is needed
  • Resolves coding edits, queries, and discrepancies in a timely and compliant manner
  • Participates in internal and external audits; assists in implementing corrective action plans
  • Collaborates with Clinical Documentation Improvement (CDI) to ensure complete documentation and optimal DRG assignment
  • Supports coding leadership by identifying documentation improvement opportunities and workflow challenges
  • Meets or exceeds departmental accuracy and productivity standards
  • Codes inpatient encounters efficiently to support timely billing and reduce DNFB
  • Assists with reviewing accounts held for coding-related issues
  • Maintains required coding credentials (CCS, RHIT, RHIA)
  • Stays current with all annual ICD-10-CM/PCS updates, DRG changes, and regulatory updates
  • Participates in continuing education, team meetings, and training sessions
  • Adapts to changing department demands required to maintain a high level of performance
  • Performs other duties as assigned

Requirements:

  • High school diploma or equivalent
  • Certified Coding Specialist (CCS) certification
  • Previous hospital coding experience
  • Possesses excellent organizational, interpersonal, verbal, and written communication skills
  • Has vigilance and keen attention to detail
  • Possesses proper phone and email etiquette for frequent hospital and private provider exchanges
  • Excellent time management to meet deadlines and productivity targets
  • Intermediate computer skills
  • Thorough knowledge of medical terminology, anatomy, and physiology
  • Understanding of ICD-10-CM, ICD-10-PCS
  • Knowledge and experience using an encoder, and EMR required.

Benefits:

  • Medical Plan
  • Prescription drug coverage & In-House Employee Pharmacy
  • Dental Plan
  • Vision Plan
  • Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA
  • Retirement Savings and Investment Plan
  • Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
  • Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
  • Disability Benefits – Long Term Disability (LTD)
  • Disability Benefits – Short Term Disability (STD)
  • Employee Assistance Program
  • Commuter Transit
  • Commuter Parking
  • Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child
  • Voluntary Legal Services
  • Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
  • Voluntary Identity Theft Insurance
  • Voluntary Pet Insurance
  • Paid Time-Off Program
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