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
