The Medical Coder (Inpatient) is responsible for accurately assigning ICD-10-CM/PCS diagnosis and procedure codes for inpatient hospital services. This ensures coded data is complete, compliant, and supports appropriate reimbursement, quality reporting, and regulatory requirements.
Key responsibilities include reviewing inpatient medical records to determine diagnoses, procedures, and complications, assigning ICD-10-CM and ICD-10-PCS codes, sequencing these accurately, ensuring documentation supports MS-DRG assignment and severity of illness and risk of mortality measurements, applying official coding guidelines and payer requirements, querying providers for clarification as needed, maintaining productivity and accuracy benchmarks, collaborating with clinical documentation improvement and billing teams, participating in audits and education initiatives, and complying with HIPAA regulations.
The role requires maintaining current knowledge of coding guidelines and certifications and performing additional duties as assigned.
Minimum of five years of Health Information Management and inpatient facility coding experience.
Associates degree required in Health Information Management, Healthcare Administration, related healthcare fields, or Business Administration/Management; Bachelor's degree preferred.
Certified Coding Specialist (CCS) credential required. Additional credentials preferred: RHIA, RHIT, CCS-P, CPC, CPMA, COC, CIC, CRC.
Advanced knowledge of medical terminology, ICD-10-CM/PCS coding, MS-DRGs, APR-DRGs, POAs, HACs, PSIs. Knowledge of documentation standards and improvement methodologies. Experience with grouper and encoder systems (3M/Nuance Clintegrity preferred) and EMRs (Epic/Powerchart preferred). Strong organizational, analytical, problem-solving, client relationship, and management skills. Proficiency in Microsoft Office. Ability to work independently in a remote environment.
Location
N/A
Employment Type
Contractor
Experience Level
Associate
Remote work allowed
Yes
Posted
1 month ago