Inpatient Medical Coder 3

Remote Position

Scope of Position
Inpatient Coding Services assigns diagnosis and procedural codes to inpatient medical records to support accurate reimbursement, regulatory compliance, and enterprise data reporting across a large academic medical center.

ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes are applied to all inpatient encounters. Medical record abstract data is captured based on clinical documentation reviewed for accuracy within the electronic health record during the coding process.

Position Summary
This position is responsible for retrospective coding of inpatient medical records at the conclusion of the patients admission, ensuring complete, accurate, and compliant code assignment in accordance with federal regulations and official coding guidelines.

The role requires advanced expertise in inpatient coding practices, including selection of the admitting diagnosis, principal and secondary diagnoses, and assignment of principal and secondary ICD-10-PCS procedures. The position is responsible for accurate ICD-10-CM and ICD-10-PCS code assignment, appropriate sequencing of diagnoses and procedures, and abstraction of required data elements, including admission source, admission type, discharge disposition, and attending and procedural physicians.

Codes are assigned using computer-assisted coding (CAC) and encoder tools following comprehensive review of the electronic medical record.

This position is responsible for resolving all system and coding edits during the coding and abstraction process and ensuring accurate MS-DRG and APR-DRG assignment to support compliant hospital reimbursement. The role requires a strong understanding of DRG methodology, including severity of illness (SOI) and risk of mortality (ROM), and the impact of coding on quality outcomes, case mix index (CMI), and reimbursement.

The position collaborates with Clinical Documentation Integrity (CDI) specialists, physician advisors, and revenue cycle partners to clarify documentation, support denial prevention efforts, and ensure adherence to coding guidelines and regulatory requirements.

This staff member is accountable for maintaining departmental productivity and quality standards, adhering to an approved work schedule, and completing required workload tracking.

Minimum Required Qualifications

High School diploma or GED required.

Credentialed as one of the following:

Registered Health Information Technician (RHIT)

Registered Health Information Administrator (RHIA) Certified Coding Specialist (CCS) through the American Health Information Management Association (AHIMA)

A minimum of two (2) years of inpatient hospital coding experience required, including ICD-10-CM/PCS code assignment and DRG assignment.

Four (4) to six (6) years of inpatient coding experience preferred.