Coder - Inpatient (Local or Remote with Experience)

UMC Health System•Richmond, KY

6d•Remote

About The Position

The Medical Coder is responsible for ICD-10 coding of diagnoses and procedures of inpatient/outpatient discharged patient records. This role requires applying diagnoses codes to in-patient, out-patient, and emergency services, and maintaining knowledge of current laws and regulations related to insurance, Medicare, Medicaid, and DRG coding, sequencing, and CPT coding. The coder will also perform quality improvement reviews as assigned and other duties related to Health Information Management. Specific duties include reviewing and analyzing inpatient medical records to assign ICD-10-CM/PCS codes, ensuring completeness for accurate DRG assignment, and maintaining knowledge of current coding guidelines. Collaboration with clinical documentation specialists is required for unclear documentation. The role also involves reviewing outpatient encounters, assigning appropriate ICD-10-CM, CPT, and HCPCS codes, ensuring accurate coding for billing and regulatory compliance, and applying NCCI edits and modifier usage. Communication with the supervisor for clarification is necessary, and the coder must meet department standards for productivity and accuracy.

Requirements

High School Diploma or GED
Completion of Medical Record Technology program
+ 2 years of experience in Health Information Management Coding
RHIT, RHIA, CCS, or coding certificate
Demonstrated skill in using 3M Encoder computer software for ICD-10-CM and CPT
Demonstrated knowledge and understanding of diseases and their treatments and operative procedures
Experience (or ability to learn) using Solventum 360 Encompass computer assisted coding
Experience (or ability to learn) using Cerner or Epic electronic health records system
Strong knowledge of medical terminology, anatomy and physiology
High attention to detail and coding accuracy
Ability to work independently and meet productivity deadlines
Excellent written and verbal communication skills
Ability to maintain patient confidentiality and comply with HIPAA and organizational policies

Responsibilities

Apply diagnoses codes to in-patient, out-patient, and emergency services
Maintain knowledge of current laws and regulations related to insurance, Medicare, Medicaid, and DRG coding, sequencing, and CPT coding
Perform quality improvement reviews as assigned
Review and analyze inpatient medical records to assign ICD-10-CM/PCS codes
Ensure completeness of the record to assign the accurate DRG (Diagnosis Related Group) assignment for reimbursement
Maintain knowledge of current coding guidelines, Coding Clinics and facility-specific coding policies
Collaborate with clinical documentation specialists as needed for unclear or inconsistent documentation requiring queries
Maintains knowledge of coding updates through provided or self- learning to ensure compliance with all changes
Maintain productivity and accuracy standards as defined by the department
Review outpatient encounters including same-day surgery and observation
Assign appropriate ICD-10-CM, CPT, and HCPCS codes based on documentation
Ensure accurate coding for billing and regulatory compliance
Apply NCCI edits and modifier usage where applicable
Communicate with supervisor to clarify documentation when necessary
Meet department standards for productivity and accuracy