Health Information Management Inpatient Coder

This is a fully remote position, open to applicants in South Carolina.

📋 Description

• Encode medical information into the Prisma billing and abstracting systems by adhering to professional and regulatory coding standards.

• Conduct inpatient coding for significant traumas and NICU records utilizing ICD and ICD-PCS codes while assigning DRGs.

• Abstract, assign, and validate MCC/CC, HAC/PSI, and Quality Indicator data through meticulous documentation validation.

• Assign suitable POA indicators and code for various facilities.

• Examine clinical documentation to determine principal diagnoses, sequence risk adjustment diagnoses, and confirm DRGs and severity indicators.

• Review and prioritize coding work queues within specified timelines.

• Follow up daily on accounts on hold to ensure final coding is completed.

• Identify and initiate physician queries when documentation is unclear or ambiguous.

• Address open queries raised by Clinical Documentation Specialists prior to final coding.

• Ensure coding is complete, accurate, timely, and consistent in alignment with Prisma Health policies.

• Achieve department standards for productivity and accuracy while escalating any coding concerns.

• Collaborate and consult with clinical documentation specialists regarding coding and documentation practices.

• Engage in training workshops and participate in CDI-Coding Task Force activities.

• Carry out additional duties as assigned.

⛳️ Requirements

• Completion of a Certification Program, Associate degree, or a Coding Certificate from the American Health Information Management (AHIMA) or another accredited coding certification program.

• Minimum of three (3) years of coding experience in an acute care or ambulatory setting.

• Experience in inpatient coding.

• Preference for familiarity with the EPIC health information system.

• Required coding credentials include RHIT, RHIA, CCS, CIC, or other recognized coding certifications.

• Understanding of electronic medical records and proficiency with 3M or Encoder System.

• Familiarity with medical terminology along with basic anatomy and physiology, pathophysiology, and pharmacology.

• Knowledge of the MS DRG prospective payment system and severity systems.

• Proficient in using official coding books, electronic medical records, computer-assisted coding/encoding software, and clinical documentation information systems.

• Ability to maintain concentration for extended periods.

• Capability to work independently and make decisions autonomously.

• Successful completion of the IP Coder Associate program or coder associate may be considered as an alternative to the stated education and experience requirements.

🏝️ Benefits

• Bonus eligible.

• Full-time employment.

• Day shift.