Position Summary

Seeking a highly skilled and experienced Inpatient Hospital Coder to join our dynamic team. The ideal candidate should possess a Certified Coding Specialist (CCS) certification and a minimum of 1 year of Inpatient coding experience. The Hospital Coder will play a crucial role in ensuring accurate coding, MS-DRG assignment, and compliance within our healthcare organization.

Work Schedule

Full-time 40-hour work week – Monday – Friday

Primary Duties

Essential Functions:

• Identifies reviews and assigns complex ICD-10-CM/PCS codes, POA indicators and PSI indicators, surgical complications to report the MS-DRG most accurately and Severity of Illness/Risk of Morality.
• Identifies reviews and assigns complex ICD-10-CM/PCS or CPT/HCPCS codes and abstracts clinical information from inpatient/outpatient types.
• Extracts pertinent information from clinical notes, operative notes, radiology reports, laboratory reports, (including Pathology), procedure records, specialty forms, etc.
• Determines complex code assignment pertinent to diagnostic workups, surgical techniques, advanced technology, and special services, identifies medical and surgical complications and untoward events for accurate MS-DRG or APC assignment.
• All coding and abstracting is for the purpose of reimbursements, research, and compliance with federal regulations and other agencies utilizing established coding principles and protocols.
• Clarifies complex discrepancies in documentation and coding; assures accuracy and timeliness of coding/abstracting assignments to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care.
• Supports special studies in relation to coding and abstracting information according to policies and procedures.
• Maintains knowledge and skills; reads current coding resources clinical information, videos, etc.
• Meets or exceeds quality and productivity standards and established department benchmarks.
• Performs other duties as assigned.

*Note: This job description is subject to change as the needs of the organization evolve.*

Qualifications/Specifications

• Education: High School diploma or equivalent required.
• Licensure/Certification: Certified Coding Specialist (CCS) or Certified Professional Coder (CPC) required.
• Experience: Minimum of 1 year of experience in medical coding with ICD-10 and CPT coding systems required. Detail-oriented and experienced coding professional with a passion for ensuring accuracy and compliance.