Hospital Inpatient Coder Certified - FT - Day - HIM Facility Coding Lawrenceville NJ

Capital Health (US)•Pike, NY

1d•Remote

About The Position

Capital Health is seeking a Certified Hospital Inpatient Coder to join their Facility Coding team in Lawrenceville, NJ. This full-time, day shift position involves reviewing and analyzing inpatient medical records to assign accurate ICD-10-CM diagnosis codes, ICD-10-PCS procedure codes, and MS-DRG/APR-DRG groupings. The role is crucial for ensuring proper reimbursement, supporting quality reporting, and maintaining compliance with official coding guidelines, payer regulations, and organizational policies. The coder will work independently while collaborating with clinicians, CDI, and revenue cycle teams as needed. The position is eligible for a variety of benefits and offers a pay range of $28.70 - $37.32 per hour.

Requirements

High school diploma or equivalent.
Certified Coding Specialist (CCS) certification.
Previous hospital coding experience.
Knowledge of medical terminology, anatomy, and physiology.
Understanding of ICD-10-CM, ICD-10-PCS.
Knowledge and experience using an encoder, and EMR required.
Excellent organizational, interpersonal, verbal, and written communication skills.
Vigilance and keen attention to detail.
Proper phone and email etiquette for frequent hospital and private provider exchanges.
Excellent time management to meet deadlines and productivity targets.
Intermediate computer skills.

Nice To Haves

Ability to work independently in a remote environment.
Ability to work under pressure.
Ability to work in a fast-paced environment with ability to meet quality and productivity standards.
Ability to interact effectively with other staff members to complete certain aspects of job.

Responsibilities

Reviews complete inpatient medical records, including physician notes, operative reports, consultations, imaging, lab results, and discharge summaries.
Assigns and properly sequences accurate ICD-10-CM diagnosis and ICD-10-PCS procedure codes in accordance with Official Coding Guidelines, UHDDS definitions, Coding Clinic guidance and CMS to a full range of inpatient services including cases with a high complexity level.
Assigns correct and optimal DRGs (MS-DRG/APR-DRG).
Ensures accurate capture of Major Comorbid Conditions (MCC)/Comorbid Conditions (CC), Present on Admission (POA) indicators, Hospital-Acquired Conditions (HACs), Patient Safety Indicators (PSIs), Severity of Illness (SOI) and Risk of Mortality (ROM).
Issues compliant physician queries when documentation is incomplete, ambiguous, or inconsistent.
Identifies documentation gaps and escalate when clarification is needed.
Resolves coding edits, queries, and discrepancies in a timely and compliant manner.
Participates in internal and external audits; assist in implementing corrective action plans.
Collaborates with Clinical Documentation Improvement (CDI) to ensure complete documentation and optimal DRG assignment.
Supports coding leadership by identifying documentation improvement opportunities and workflow challenges.
Meets or exceeds departmental accuracy and productivity standards.
Codes inpatient encounters efficiently to support timely billing and reduce DNFB.
Assists with reviewing accounts held for coding-related issues.
Maintains required coding credentials (CCS, RHIT, RHIA).
Stays current with all annual ICD-10-CM/PCS updates, DRG changes, and regulatory updates.
Participates in continuing education, team meetings, and training sessions.
Adapts to changing department demands required to maintain high level of performance.
Performs other duties as assigned.