Inpatient Coder III
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AI Summary
Responsible for accurately assigning ICD-10-CM and ICD-10-PCS codes to inpatient medical records while ensuring compliance with regulatory guidelines. Collaborates with CDI teams and providers to optimize coding accuracy and financial integrity.
Job Summary
The Inpatient Coder is responsible for accurately assigning ICD-10-CM and ICD-10-PCS codes to inpatient medical records, ensuring compliance with coding guidelines, reimbursement policies, and corporate standards. This role supports Health Information Management (HIM) Central Services and works to review inpatient documentation, apply accurate codes, and collaborate with clinical documentation integrity (CDI) teams to optimize coding accuracy and financial integrity.
Essential Functions
The Inpatient Coder is responsible for accurately assigning ICD-10-CM and ICD-10-PCS codes to inpatient medical records, ensuring compliance with coding guidelines, reimbursement policies, and corporate standards. This role supports Health Information Management (HIM) Central Services and works to review inpatient documentation, apply accurate codes, and collaborate with clinical documentation integrity (CDI) teams to optimize coding accuracy and financial integrity.
Essential Functions
- Performs remote inpatient coding for CHS-supported hospitals, reviewing electronic medical records (EMR) and provider documentation to assign accurate diagnosis and procedure codes.
- Ensures compliance with ICD-10-CM and ICD-10-PCS coding guidelines, payer-specific rules, and regulatory requirements.
- Submits queries to providers for documentation clarification when necessary to ensure coding specificity and clinical accuracy.
- Collaborates with CDI teams to ensure complete, compliant, and accurate coding based on available clinical documentation.
- Maintains productivity and accuracy benchmarks, achieving a 95% coding accuracy rate while meeting corporate productivity standards.
- Consults with the Manager or other available resources to resolve complex coding issues and discrepancies.
- Identifies documentation deficiencies or potential opportunities for physician education and process improvement.
- Assists with coding audits and quality reviews, ensuring adherence to compliance standards and corporate policies.
- Maintains strict confidentiality of patient records, ensuring compliance with HIPAA and HIM privacy regulations.
- Performs other duties as assigned.
- Maintains regular and reliable attendance.
- Complies with all policies and standards.
- H.S. Diploma or GED required
- Associate Degree in Health Information Management, Medical Coding, or a related field preferred or
- One (1) year coding certification in Health Information Management preferred
- 1-3 years of inpatient coding experience in an acute care hospital or health system including coding complex cardiac and neuroscience procedures required
- Experience with virtual desktop image, electronic medical record systems, encoding systems as well as word processing and spreadsheet software required
- Experience in both inpatient and outpatient coding, with knowledge of MS-DRG and APR-DRG reimbursement methodologies preferred
- Strong knowledge of ICD-10-CM and ICD-10-PCS coding principles, guidelines, and reimbursement methodologies.
- Familiarity with CDI best practices and clinical indicators for accurate documentation and coding.
- Experience working with electronic health records (EHR) and coding software (e.g., 3M, EPIC, Meditech, Cerner, or other HIM platforms).
- Ability to work independently in a remote setting, meeting productivity and accuracy expectations.
- Strong analytical, problem-solving, and communication skills to collaborate with physicians, CDI teams, and coding managers.
- Knowledge of HIPAA regulations and patient data privacy standards.
- Certified Coding Specialist (CCS) – AHIMA required or
- RHIT - Registered Health Information Technician AHIMA required or
- RHIA - Registered Health Information Administrator AHIMA required
- Certified Inpatient Coder (CIC) – AAPC preferred
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