HOSPITAL INPATIENT CODER SR
About The Position
The Hospital Inpatient Coder Senior assigns ICD-10-CM diagnosis codes, ICD-10-PCS procedure codes, and MS-DRGs for complex hospital inpatient services. The role applies clinical knowledge of disease processes, physiology, pharmacology, and surgical techniques to review and interpret clinical documentation in inpatient records. It abstracts data in compliance with national and regional policies and clarifies physician documentation through the facility-established query process. The coder follows applicable coding and sequencing guidance, including ICD-10-CM/ICD-10-PCS Official Coding Guidelines, the Uniform Hospital Discharge Data Set, CMS guidelines, and other relevant resources. The position serves as a subject matter expert, supports less experienced team members in following operational policies, trains and onboards new team members, and participates in special projects assigned by Mid Revenue Cycle leadership.
Requirements
- High school diploma or GED.
- Five years of hospital inpatient coding experience with ICD-10 diagnosis and procedure codes and MS-DRG.
- One of the following certifications: CCS, CPC, COC, CCS-P, RHIT, RHIA, or CIC. Other certifications may be considered if issued by AHIMA or AAPC.
- Thorough understanding of how data quality affects prospective payment, utilization, and reimbursement across multiple medical specialties.
- Experience coding hospital inpatient electronic medical records.
- Excellent communication and interpersonal skills.
- Experience with automated patient care and coding systems.
- Competence with MS Office software.
- Extensive knowledge of AHA Coding Clinic guidelines; ICD-10-CM and ICD-10-PCS coding guidelines; MS-DRG and APR-DRG; CMS guidelines; and NCHS.
Nice To Haves
- Associate's degree in healthcare or a related field.
- Experience coding oncology-related services.
Responsibilities
- Assign ICD-10-CM diagnosis codes, ICD-10-PCS procedure codes, and MS-DRGs for complex hospital inpatient services.
- Review and interpret clinical documentation in inpatient records using knowledge of disease processes, physiology, pharmacology, and surgical techniques.
- Abstract data in compliance with national and regional policies.
- Clarify physician documentation using the facility-established query process.
- Apply diagnosis and procedure sequencing guidance and relevant coding guidelines.
- Serve as a subject matter expert and assist less experienced team members with operational policies.
- Train and onboard new team members.
- Participate in special projects assigned by Mid Revenue Cycle leadership.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
Education Level
High school or GED
