Inpatient Coder - HIM

The Health Information Management (HIM) Coder plays a key role in impacting healthcare quality initiatives and reimbursement by assigning accurate diagnosis and procedural codes to patient health records for data retrieval, analysis, and claims processing. Reporting to the HIM Coding and Clinical Documentation Integrity Manager, the coder analyzes physician documentation (electronic, paper, or hybrid) to determine principal and secondary diagnoses and procedure codes, ensuring correct MS-DRG assignment.

Utilizes CPT, HCPCS codes and modifiers per coding rules and regulations. Coding supports APC determination for analysis, quality research, and claim submission. The coder follows AHIMA's Standards of Ethical Coding and contributes positively to patient and family-centered care.

Key responsibilities include:

• Adhering to hospital mission, policies, confidentiality, corporate compliance, and ethical standards
• Coding accounts based on priority and using encoder software tools for ICD-CM and ICD-PCS codes
• Meeting productivity metrics with high accuracy
• Completing records with required documentation details
• Investigating unbilled accounts for completion
• Querying providers for clarification following compliant query guidelines
• Reviewing and responding to claim edits (NCCI, OCE, LCD, NCD)
• Keeping current with coding guidelines and maintaining proficiency with software applications (3-M, Meditech, scanning software)
• Training and orienting new staff
• Working efficiently in a remote environment

This position requires an Associate's degree in Health Information Technology, completion of a registered coding program with AHIMA approval (RHIA, RHIT, or CCS), and at least three years of acute care hospital coding experience, including knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG grouping, anatomy, physiology, and computer application competency.