Health Information Management Inpatient Coder

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

📋 Description

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

• Conduct inpatient coding for major trauma and NICU records utilizing ICD, ICD-PCS, and DRG assignment.

• Abstract and validate MCC/CC, HAC/PSI, and Quality Indicator information through thorough documentation checks.

• Assign appropriate POA indicators and code for various facilities.

• Examine work queues, prioritize charts, and complete final coding within specified timelines.

• Follow up daily on accounts on hold for final coding completion.

• 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 accordance with Prisma policies.

• Identify and analyze coding issues, escalating concerns as necessary.

• Consult and collaborate with clinical documentation specialists regarding coding and documentation practices.

• Perform additional duties as assigned.

⛳️ Requirements

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

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

• Experience in inpatient coding.

• Preferred experience with EPIC health information systems.

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

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

• Familiarity with electronic medical records and the 3M or Encoder System.

• Knowledge of medical terminology, basic anatomy and physiology, pathophysiology, and pharmacology.

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

• Ability to maintain focus for extended periods.

• Capability to work independently and make decisions autonomously.

🏝️ Benefits

• Eligibility for bonuses.

• Access to on-site, remote, and/or external training workshops.

• Opportunities for collaborative training and education with CDI, PFS, and Quality.