The Inpatient Coder is responsible for accurately assigning diagnostic and procedure codes to inpatient encounters based on electronic medical record documentation while maintaining compliance with established coding rules and regulatory guidelines.
Key responsibilities include:
- Reviewing inpatient medical record documentation to determine principal and secondary diagnoses, comorbid conditions, complications, and procedures
- Assigning accurate ICD-10-CM and ICD-10-PCS codes using an electronic encoder
- Abstracting clinical data into the EHR and coding/abstracting systems
- Querying physicians when diagnoses or procedures need clarification
- Maintaining coding quality, productivity, and turnaround standards
- Supporting accounts receivable goals related to uncoded accounts
- Participating in coding meetings, education, and quality improvement efforts
Requirements & Qualifications
- Associate’s degree or higher in a CAHIIM-accredited program, or two additional years of experience in lieu of degree
- At least 1 year of relevant inpatient coding experience, or completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program
- One of the following certifications required:
- RHIT
- RHIA
- CCS
- Strong knowledge of coding classification systems, DRG/APC systems, official coding guidelines, and coding compliance
- Working knowledge of medical terminology, anatomy, and physiology
- Preferred experience with electronic medical records, imaging systems, and encoder applications
- Strong computer skills with common office software, coding software, and abstracting systems
- Effective communication skills and ability to work with patients, physicians, family members, and co-workers
Location
Georgia, US
Employment Type
Full-time
Experience Level
Associate
Remote work allowed
No
Posted
3 weeks ago
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