Inpatient Coder

To abstract and code compliantly, accurately and completely, grouping each account to the appropriate DRG to facilitate data quality and ensure accurate and timely reimbursement.

Responsibilities include verifying, reviewing, analyzing, and abstracting medical information; researching missing information; assigning accurate codes; querying physicians as needed; elevating documentation issues; ensuring valid orders prior to coding; and communicating with HIM Director about obstacles. Proficiency in inpatient coding and DRG grouping is essential.

Key duties:

• Maintain a 95% or higher accuracy rate in coding
• Code 3.5 to 4 inpatient accounts per hour
• Clarify documentation issues by querying physicians
• Notify management of missing or unsigned admission orders
• Abstract medical record information into coding modules
• Collaborate with coding director and serve as resource to other coders
• Manage time effectively to meet deadlines
• Stay updated on coding changes through continuous education

Behavioral standards include supporting company mission, demonstrating positive customer service, professionalism, accountability, participation in improvement activities, continual learning, and adhering to company code of conduct.

Education and qualifications:

• Graduate of AHIMA coding program, RHIT or RHIA
• AS or BS degree preferred
• 3-5 years inpatient coding experience preferred
• Advanced knowledge of ICD-10-CM, ICD-10-PCS, medical terminology, anatomy, physiology, disease processes, and pharmacology
• Proficient with encoder systems and DRG/MS-DRG grouping
• Strong PC and software skills
• Ability to work independently

Certifications required: CCS, CPC, RHIT or RHIA credential from AHIMA or AAPC.