Hospital Inpatient Coder, Certified

This is a fully remote position, open to applicants in United States.

📋 Description

• Reviews comprehensive inpatient medical records, which include physician notes, operative reports, consultations, imaging, lab results, and discharge summaries.

• Assigns and sequences accurate ICD-10-CM diagnosis and ICD-10-PCS procedure codes in line with Official Coding Guidelines, UHDDS definitions, Coding Clinic guidance, and CMS for a wide variety of inpatient services, including those with high complexity levels.

• Assigns appropriate and optimal DRGs (MS-DRG/APR-DRG).

• Ensures the accurate capture of Major Comorbid Conditions (MCC)/Comorbid Conditions (CC), Present on Admission (POA) indicators, Hospital-Acquired Conditions (HACs), Patient Safety Indicators (PSIs), Severity of Illness (SOI), and Risk of Mortality (ROM).

• Issues compliant queries to physicians when documentation is incomplete, ambiguous, or inconsistent.

• Identifies gaps in documentation and escalates issues when clarification is required.

• Resolves coding edits, queries, and discrepancies promptly and in compliance with regulations.

• Participates in internal and external audits, providing assistance in the implementation of corrective action plans.

• Collaborates with Clinical Documentation Improvement (CDI) teams to ensure complete documentation and optimal DRG assignment.

• Supports coding leadership by identifying opportunities for documentation improvement and addressing workflow challenges.

• Meets or surpasses departmental standards for accuracy and productivity.

• Efficiently codes inpatient encounters to facilitate timely billing and minimize DNFB.

• Assists in reviewing accounts that are on hold due to coding-related issues.

• Maintains necessary coding credentials (CCS, RHIT, RHIA).

• Remains updated with all annual ICD-10-CM/PCS revisions, DRG changes, and regulatory updates.

• Engages in continuing education, team meetings, and training sessions.

• Adapts to evolving departmental demands to sustain a high level of performance.

• Performs additional duties as assigned.

⛳️ Requirements

• High school diploma or equivalent.

• Certification as a Certified Coding Specialist (CCS).

• Previous experience in hospital coding.

• Excellent organizational, interpersonal, verbal, and written communication skills.

• Strong attention to detail and vigilance.

• Proficient phone and email etiquette for regular exchanges with hospitals and private providers.

• Exceptional time management skills to meet deadlines and productivity goals.

• Intermediate computer proficiency.

• Comprehensive knowledge of medical terminology, anatomy, and physiology.

• Understanding of ICD-10-CM and ICD-10-PCS.

• Experience using an encoder and EMR is required.

🏝️ Benefits

• Medical Plan.

• Prescription drug coverage & In-House Employee Pharmacy.

• Dental Plan.

• Vision Plan.

• Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA.

• Retirement Savings and Investment Plan.

• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance.

• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance.

• Disability Benefits – Long Term Disability (LTD).

• Disability Benefits – Short Term Disability (STD).

• Employee Assistance Program.

• Commuter Transit.

• Commuter Parking.

• Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child.

• Voluntary Legal Services.

• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance.

• Voluntary Identity Theft Insurance.

• Voluntary Pet Insurance.

• Paid Time-Off Program.