Health Information Management Inpatient Coder

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

📋 Description

• Encodes medical data into the Prisma billing and abstracting systems by following established professional and regulatory coding standards.

• Ensures appropriate assignment of the diagnosis present on admission (POA) indicators.

• Performs coding for various facilities.

• Complies with Prisma Health Coding and Compliance policies and procedures to ensure the assignment of complete, precise, timely, and consistent codes.

• Conducts Inpatient coding, including major traumas and Neonatal Intensive Care Unit (NICU) records, by assigning International Classification of Diseases (ICD) codes, International Classification of Diseases-Procedure Coding System (ICD-PCS) codes, and determining Diagnosis Related Groups (DRG).

• Abstracts, assigns, and verifies codes for Major Complications and Comorbidities/Complications and Comorbidities (MCC/CCs), Hospital-Acquired Conditions/Patient Safety Indicators (HAC/PSI), and captures Quality Indicators as appropriate through documentation validation.

• Confirms the assignment of DRGs, MCC/CCs, Hospital-Acquired Conditions (HACs), and Patient Safety Indicators (PSIs) that accurately reflect documentation of event occurrences, illness severity, and resources utilized during the inpatient stay, in accordance with department policies and procedures.

• Chooses the optimal principal diagnoses with the correct POA indicator assignment and sequencing of risk adjustment diagnoses based on established guidelines.

• Reviews work queues to identify charts needing coding and prioritizes them according to department-specific guidelines and within set timelines.

• Conducts daily follow-ups on on-hold accounts to finalize coding.

• Recognizes and requests physician queries according to established guidelines when existing documentation is unclear or ambiguous, adhering to American Health Information Management (AHIMA) guidelines and established organizational policies.

• Ensures all open queries initiated by Clinical Documentation Specialists are resolved prior to final coding.

• Follows department standards for productivity and accuracy.

• Identifies and tracks coding issues, escalating any concerns as necessary.

• Consults with and provides professional expertise to clinical documentation specialists regarding coding and documentation practices and standards.

⛳️ Requirements

• Completion of a Certification Program or an Associate degree or Coding Certificate through American Health Information Management (AHIMA) or another recognized coding certification program.

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

• Experience in inpatient coding.

• Preferred experience with the EPIC health information system.

• Possession of a Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), or other recognized coding credentials.

🏝️ Benefits

• Inspire health.

• Serve with compassion.

• Be the difference.