Inpatient Coder Senior

Job Summary

The Senior Inpatient Coder reviews inpatient record accounts to assign accurate ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes in accordance with industry coding guidelines. The role uses 3M computer-assisted coding software and abstracts coded data from the Epic electronic medical record while maintaining quality and productivity standards.

This position also reviews outpatient service lines, including ambulatory surgery, observation, interventional radiology/cardiology, and emergency records, assigning ICD-10-CM diagnosis codes, CPT procedure codes, modifiers, and reviewing claim edits as needed. The coder works collaboratively with leadership, financial teams, and clinical staff to support DRG and APR-DRG accuracy.

Essential Functions

• Review inpatient and outpatient records according to coding guidelines and conventions
• Assign diagnosis and procedure codes for billing, data retrieval, and research purposes
• Work in an electronic medical record and encoder in a remote environment
• Optimize codes for reporting and generate APCs for outpatient records
• Provide education and training on coding guidelines to clinical and non-clinical staff
• Collaborate with team members to ensure continuity of services
• Participate in process improvement activities
• Attend required staff meetings