Inpatient Coder
2 days ago
Job Summary
The Inpatient Coder is responsible for accurately reviewing, analyzing, and assigning ICD-10-CM and ICD-10-PCS codes to inpatient medical records for the purpose of reimbursement, research, and compliance with federal regulations. This role ensures that all coding meets established accuracy, timeliness, and productivity standards in accordance with hospital policies and official coding guidelines.
Key Responsibilities
- Review and analyze inpatient medical records to identify diagnoses and procedures requiring coding.
- Assign accurate and complete ICD-10-CM diagnosis and ICD-10-PCS procedure codes based on physician documentation and coding guidelines.
- Ensure coding accuracy to support appropriate DRG (Diagnosis-Related Group) assignment for billing and reimbursement.
- Abstract and enter required data elements into the hospital's health information system.
- Validate documentation to ensure compliance with payer-specific and government regulations.
- Collaborate with physicians, clinical documentation specialists, and other healthcare staff to clarify diagnoses or procedures when documentation is incomplete or ambiguous.
- Maintain coding productivity and quality benchmarks as defined by departmental standards.
- Stay current with changes in coding guidelines, regulations, and industry practices.
- Participate in ongoing education and quality improvement activities.
Qualifications
Education:
- Associate's or Bachelor's degree in Health Information Management, Health Sciences, or a related field (preferred).
Certification:
- Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), or Registered Health Information Administrator (RHIA) credential from AHIMA required/preferred.
Experience:
- Minimum of 2 years of inpatient coding experience in an acute care hospital setting preferred.
- Strong knowledge of ICD-10-CM, ICD-10-PCS, DRG assignment, and medical terminology.
Skills:
- High attention to detail and accuracy.
- Strong analytical and problem-solving skills.
- Proficiency with electronic health records (EHR) and coding software.
- Ability to work independently and meet strict deadlines.
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