The Inpatient Coder II is responsible for reviewing inpatient medical records and assigning ICD-10-CM and ICD-10-PCS codes to support accurate diagnosis-related group (DRG) assignment and optimal reimbursement. The role works closely with the Clinical Documentation Improvement (CDI) team, management, and other departments to ensure coding accuracy, compliance with state and federal guidelines, and timely completion of inpatient coding work.
Key responsibilities include:
- Assign ICD-10-CM and ICD-10-PCS codes for inpatient accounts
- Abstract relevant information from patient records and sequence diagnoses/procedures correctly
- Apply present-on-admission (POA) indicators and verify discharge disposition
- Collaborate with CDI on DRG, principal diagnosis, CC/MCC, HAC, PSI, and SOI/ROM mismatches
- Query physicians when documentation is unclear or incomplete
- Meet turnaround time and productivity standards
- Support DNFB, denial, and claim edit goals
- Participate in coding education, audit review, rebuttals, and coding policy development
Requirements & Qualifications
Education:
- High School Diploma or GED required
- Program graduate in Health Information Management Services (HIMS) or related field preferred
Experience:
- 3-4 years of active inpatient coding (acute care) required
Certifications:
- One of the following required: CCS, CCA, RHIA, RHIT, or CIC
Skills and abilities:
- Strong knowledge of medical terminology, disease processes, anatomy and physiology, pathophysiology, and laboratory medicine
- Effective verbal and written communication skills
- Proficiency with Microsoft Office, coding encoders, and electronic medical records
- Familiarity with 3M 360 and EPIC preferred
Location
Virginia, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
Yes
Posted
4 weeks ago
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