AT A GLANCE
Full Time / Long Term
Senior Remote Inpatient Coder
Under general supervision the Senior Certified Inpatient Medical Coding Specialist is responsible in reviewing and abstracting inpatient medical records identifying and assigning accurate medical codes for diagnosis, procedures and services in an inpatient setting. Coding Specialist ensures that all data elements required for federal or state reporting and billing are collected and included in the patient’s demographic record.
Specific age groups that are served by this position include:
- At least 3 years acute care coding experience.
- Four (4) years of hospital inpatient coding; years of experience can be substituted with demonstrated competency levels for this position are met. Levels are based on knowledge, performance, accuracy and quality.
- Bachelor's degree or Associates degree in medical record technology or health information management; in lieu of a degree two (2) years of demonstrated proficiency in inpatient coding experience in addition to qualifications listed below.
- Certified Coding Specialist (CCS) required or in the process of renewal. RHIA and/or RHIT preferred.
- Must be able to demonstrate knowledge and skills necessary to provide care appropriate to the patient served.
- Must demonstrate knowledge of the principles of growth and development as it relates to the different life cycles.
- Proficient knowledge of ICD-10 coding.
- Strong analytical skills necessary to interpret data contained in the health records and to assign appropriate codes.
- Able to meet established productivity standards.
- Able to maintain an accuracy level of 92% - 95%.
- Able to meet the three (3) or less abstracting errors requirement monthly.
- Proficient knowledge of human anatomy, physiology, medical terminology and surgical terminology.
- Proficient critical thinking, good judgment and decision making skills.
- Proficient knowledge of coding compliance policies, official coding guidelines, regulatory requirements and internal policies and procedures affecting the coding process.
- Effective written and verbal communications skills.
- Proficient in navigating a Windows based application environment.
- Review medical record documentation to identify pertinent diagnosis/procedures that require code assignment for inpatient, observation and diagnostic procedures records and accurately code the diagnoses and procedures using ICD-10PCS/CM coding conventions for the purpose of reimbursement, research, and compliance with federal regulations.
- Review the medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and professional charges.
- Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
- Keeps abreast of coding guidelines and reimbursement reporting requirements. Brings identified concerns to supervisor or department manager for resolution.
- Effectively assigns ICD-10PCS/CM or HCPCS codes, or DRG group assignments.
- Responsible in maintaining 92% to 95% DRG and Coding accuracy levels, in meeting established productivity standards and 3 or less abstracting errors to meet expectations for this level.
- Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
- Ensures safe care to patients, staff and visitors; adheres to all policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.