Inpatient Medical Coder

AdventHealth•Orlando, FL

11h

About The Position

The Inpatient Medical Coder assigns ICD-10-CM/PCS codes for inpatient medical records based on clinical documentation and ensures accurate DRG assignment that reflects patient acuity and severity of illness. The role reviews documentation for MCC/CC capture opportunities and coding accuracy while maintaining productivity and turnaround-time standards that support DNFB reduction and revenue cycle performance. The coder applies coding guidelines, regulatory requirements such as IPPS and CMS rules, and payer requirements to ensure compliant coding practices. The position identifies documentation gaps and collaborates with CDI for clarification when appropriate or as indicated by established workflows. It also incorporates audit feedback and education into daily practice, participates in quality reviews, responds to audit findings and performance-improvement initiatives, and maintains current knowledge of coding updates, regulatory changes, and organizational standards. Other duties may be assigned.

Requirements

High school graduate or equivalent.
At least 2 years of acute care hospital inpatient coding experience or completion of the AdventHealth inpatient coding training.
One of the following required credentials: Certified Coding Specialist (CCS), Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), or Certified Professional Coder (CPC).
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.

Nice To Haves

Completion of the AdventHealth inpatient surgical coding training program may be considered in lieu of work experience.

Responsibilities

Assign ICD-10-CM/PCS codes for inpatient medical records based on clinical documentation.
Ensure accurate DRG assignment reflecting patient acuity and severity of illness.
Review documentation for MCC/CC capture opportunities and coding accuracy.
Maintain productivity and turnaround-time standards to support DNFB reduction and revenue cycle performance.
Apply coding guidelines, regulatory requirements including IPPS and CMS, and payer rules to ensure compliant coding.
Identify documentation gaps and collaborate with CDI for clarification when appropriate or as indicated by CDI/Coding workflows.
Incorporate audit feedback and education into daily coding practice.
Participate in quality reviews and respond to audit findings and performance-improvement initiatives.
Maintain current knowledge of coding updates, regulatory changes, and organizational standards.
Perform other duties as assigned.