The Inpatient Coding Apprentice evaluates medical records and documentation for completeness, accuracy, and compliance with ICD-10-CM, HCPCS, CMS documentation requirements, and CPT guidelines. The role reviews complex medical records to identify diagnoses, procedures, and principal diagnosis/principal procedure assignments using UHDDS definitions, ensures appropriate DRG assignment, abstracts relevant information from the medical record, and identifies documentation issues. The position also involves requesting clarification from physicians when documentation is ambiguous or conflicting and maintaining strict confidentiality in accordance with HIPAA requirements. The apprentice may also provide technical guidance and training on medical coding to physicians and staff.
Education
- High school diploma or equivalent required.
Experience
- Experience in medical terminology and anatomy/physiology preferred.
Certifications / Training
- Must have de-escalation training completed by the end of orientation (90 days).
- Must meet the appropriate level of de-escalation training.
- Must successfully pass the Medical Records Coding tests (CPT and ICD-10) with a score of at least 70%.
Knowledge / Skills
- Knowledge of anatomy, physiology, medical terminology, and DRGs/APCs.
- Ability to evaluate complex medical records and assign accurate coding.
- Strong attention to detail, communication, and decision-making skills.
- Proficiency with computers, MS Outlook, and Word.
- Ability to work under pressure, meet deadlines, and maintain collaborative working relationships.
- Ability to travel throughout the SRHS service area with personal transportation.
Location
Mississippi, US
Employment Type
Full-time
Experience Level
Internship
Remote work allowed
No
Posted
3 weeks ago