Hospital Inpatient Coder

Cedars-Sinai•Los Angeles, CA

12h•$44 - $68•Remote

About The Position

Cedars Sinai, an organization with a reputation for excellence and recipient of the National Research Corporation’s Consumer Choice Award for 19 consecutive years, is seeking a Hospital Inpatient Coder. This role operates under the general direction of a coding supervisor and is responsible for assigning ICD-10-CM and ICD-10-PCS codes by reviewing all appropriate documentation in accordance with standard coding guidelines. The coder will identify the principal diagnosis, comorbidities/complications, present on admission indicators, and determine code sequencing to calculate the most appropriate DRG representing the patient stay. Maintaining knowledge of both Medicare Severity Diagnosis Related Groups (MS-DRG) and All Patient Refined Diagnosis Related Groups (APR-DRG) is required. Additionally, incumbents must maintain knowledge of appropriate capture of codes for statistical purposes such as Social Determinants of Health (SDOH), Hierarchical Conditions (HCC), and severity impacting conditions. The role involves reviewing medical documentation within various electronic systems, abstracting data, applying coding knowledge, resolving complex inpatient edits, and communicating with the Clinical Documentation Integrity Team. The position requires a focus on advanced level concepts and translating medical records into standardized codes for patients within the Cedars Sinai Health System and its affiliates. Collaboration with the CDI team is essential to align clinical and coding approaches. Data abstraction is also required for statistical requests, and opportunities for documentation improvement should be identified.

Requirements

High school diploma or GED required.
A minimum of 3 years’ work experience doing code assignment in a healthcare setting performing similar coding duties required.
Registered Health Info Tech, Registered Health Info Admin, Certified Professional Coder, Certified Coding Specialist, or Certified Coding Spec Phys required upon hire.

Responsibilities

Reviews medical documentation/health information within various electronic medical/health system(s) and assigns applicable codes (ICD-10-CM, ICD-10-PCS) within productivity and quality standard for area(s) of assignment/specialty (Facility or Professional).
Abstracts all required data elements for reporting and statistical capture in a timely and accurate manner into the applicable system using the applications appropriate to the work assignment. This may include but not limited to: EPIC (CS-Link), EPIC HB and PB modules, Solventum 360Encompass, Solventum Standalone Encoder, Select Coder, etc.
Applies basic knowledge of industry requirements of specific category coding and the impact (SDOH, PSI).
Resolves complex inpatient edits/alerts with consistent accuracy using current guidelines within area(s) of assignment/specialty.
Communicates with Clinical Documentation Integrity Team members regarding complex clinical scenarios to ensure all relevant codes are assigned.
Focuses learning on advanced level concepts.
Translates medical records/health information including diagnoses, procedures and treatment and assigns standardized codes (International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), International Classification of Diseases, Tenth Revision, and Procedure Coding System (ICD-10-PCS) for patients receiving services within the Cedars Sinai Health System and its affiliates.
Communicates collaboratively with the Clinical Documentation Integrity (CDI) team to align both clinical and coding approaches to ensure a complete coding profile. References anatomy, physiology, and clinical practice to support code assignment and contribute to CDI discussions.
Abstracts data elements to satisfy statistical requests by the health system, medical staff, and enters all coded/abstracted information into the assigned system. Identifies opportunities for documentation improvement and seeks clarity by the physicians.