Inpatient Medical Coder

AdventHealth•Orlando, FL

1d•Onsite

About The Position

Assigns ICD-10-CM/PCS codes for inpatient medical records based on clinical documentation. Ensures accurate DRG assignment reflecting patient acuity and severity of illness. Reviews documentation to identify MCC/CC capture opportunities and coding accuracy. Maintains productivity and turnaround time standards to support DNFB reduction and revenue cycle performance. Applies coding guidelines, regulatory requirements (IPPS, CMS) and payer rules to ensure compliant coding practices. Identifies documentation gaps and collaborates with CDI for clarification when appropriate or as indicated by CDI/Coding workflows. Incorporates audit feedback and education into daily coding practice to ensure consistency and continuous improvement. Participates in quality reviews and responds to audit findings and performance improvement initiatives. Maintains current knowledge of coding updates, regulatory changes, and organizational standards. Performs other duties as assigned.

Requirements

Ability to interpret clinical documentation and its impact on coding and DRG assignment
Knowledge of ICD-10-CM coding, low acuity procedures, and inpatient reimbursement (IPPS)
Understanding of CDI processes and documentation requirements
Ability to identify coding and documentation risks
Ability to write compliant queries
Strong analytical and problem-solving skills
Effective communication and collaboration across clinical, CDI, and coding teams
High School Grad or Equiv
2+ years acute care hospital inpatient coding or completion of the AdventHealth inpatient coding training
Certified Coding Specialist (CCS) OR Registered Health Information Administrator (RHIA) OR Registered Health Information Technician (RHIT) OR Certified Professional Coder (CPC)

Nice To Haves

AdventHealth inpatient surgical coding training program completion may be considered in leu of work experience

Responsibilities

Assigns ICD-10-CM/PCS codes for inpatient medical records based on clinical documentation
Ensures accurate DRG assignment reflecting patient acuity and severity of illness
Reviews documentation to identify MCC/CC capture opportunities and coding accuracy
Maintains productivity and turnaround time standards to support DNFB reduction and revenue cycle performance
Applies coding guidelines, regulatory requirements (IPPS, CMS) and payer rules to ensure compliant coding practices
Identifies documentation gaps and collaborates with CDI for clarification when appropriate or as indicated by CDI/Coding workflows
Incorporates audit feedback and education into daily coding practice to ensure consistency and continuous improvement
Participates in quality reviews and responds to audit findings and performance improvement initiatives
Maintains current knowledge of coding updates, regulatory changes, and organizational standards
Performs other duties as assigned