Under direct supervision, the Inpatient Coder is responsible for accurate coding and abstracting of inpatient cases and services from medical record documentation. This role assigns codes and modifiers using ICD-CM, ICD-PCS, CPT, HCPCS, and other specialty systems as required.
The coder also reviews and abstracts Observation, Hospital Ambulatory Surgery, Emergency Department, and complex Hospital Outpatient Visit services when needed. Work must follow all applicable coding regulations, conventions, and organizational guidelines.
Key responsibilities include reviewing medical record documentation, sequencing diagnoses and procedures correctly, determining DRG accuracy, ensuring data integrity, interacting with physicians for clarification, and meeting productivity and quality standards.
Experience
- Three years of continuous hospital coding experience within the last five years.
Education
- High School Diploma or GED.
- Completion of coursework in medical terminology, anatomy, physiology, ICD-CM, ICD-PCS, CPT coding conventions, and disease processes from an accredited program.
Credentials
- Certified Coding Specialist, Registered Health Information Technician, or Registered Health Information Administrator.
Additional Qualifications
- Must score at least 75% on the KP Inpatient Coding test.
- Must meet productivity and quality standards.
- Strong understanding of medical record review and coding compliance.
- Knowledge of anatomy, physiology, medical terminology, disease processes, and reimbursement methodologies.
- Ability to communicate with physicians regarding diagnosis and procedure clarification.
- Must maintain coding credential and complete required continuing education units.
- Must abide by AHIMA and AAPC code of ethics.
- Must be willing to work in a Labor Management Partnership environment.
Location
California, US
Employment Type
Full-time
Experience Level
Intermediate Level
Remote work allowed
No
Posted
3 weeks ago