Inpatient Medical Coder / Coder Abstractor - Hospital System

Inpatient Medical Coder / Coder Abstractor

We are seeking an experienced Inpatient Medical Coder III / Coder Abstractor to join a healthcare organization in New York, NY. This position is responsible for accurately reviewing, coding, and abstracting inpatient medical records in accordance with established coding guidelines, regulatory requirements, and industry standards. The ideal candidate will have extensive experience with inpatient coding, a strong understanding of ICD-10-CM/PCS classification systems, and expertise in MS-DRG and APR-DRG assignment. This individual will play a key role in ensuring coding accuracy, documentation integrity, regulatory compliance, and timely reimbursement.

Key Responsibilities

• Review and abstract inpatient medical records to assign accurate diagnosis and procedure codes.
• Apply ICD-10-CM and ICD-10-PCS coding guidelines to ensure accurate, complete, and compliant coding.
• Assign codes to the highest level of specificity supported by clinical documentation.
• Apply official coding guidelines, including those established by the American Hospital Association (AHA).
• Accurately assign and validate MS-DRG and APR-DRG classifications, including Risk of Mortality (ROM) and Severity of Illness (SOI).
• Review medical documentation for completeness and identify discrepancies requiring clarification.
• Perform physician queries when additional documentation is necessary to support accurate coding.

Coding Quality & Compliance

• Maintain a minimum quarterly coding accuracy rate of 95%.
• Meet established coding productivity and quality standards.
• Ensure compliance with federal, state, and organizational coding regulations.
• Conduct limited documentation analysis to validate coding decisions.
• Complete coding follow-up activities within established deadlines to support timely billing.
• Escalate documentation and coding issues appropriately to prevent reimbursement delays.
• Maintain confidentiality and comply with HIPAA and applicable privacy requirements.

Technology & Coding Systems

• Utilize electronic health records (EHR) and coding applications to review documentation, assign codes, and complete abstraction.
• Work with coding and clinical documentation systems, including:
• Solventum (formerly 3M) 360 Encompass
• Epic
• CloudMed
• Iodine
• SmarterDx
• Maintain accurate electronic coding records and documentation.
• Utilize Microsoft Excel and other reporting tools as needed.

Professional Development & Collaboration

• Stay current with ICD-10-CM/PCS updates, coding regulations, and reimbursement methodologies.
• Maintain required professional coding certifications and credentials.
• Participate in continuing education, coding training, and competency assessments.
• Attend departmental meetings and educational sessions.
• Collaborate with coding leadership, clinical documentation specialists, and healthcare providers to resolve coding questions.
• Perform additional related duties as assigned.

Qualifications

Required

• High school diploma or GED.
• Approximately 36 years of relevant coding experience, including inpatient medical coding.
• Advanced knowledge of ICD-10-CM and ICD-10-PCS coding systems.
• Strong understanding of MS-DRG, APR-DRG, Severity of Illness (SOI), and Risk of Mortality (ROM) assignment.
• Comprehensive knowledge of medical terminology, anatomy, and physiology.
• Ability to interpret complex clinical documentation and accurately assign diagnosis and procedure codes.
• Familiarity with inpatient reimbursement methodologies and coding compliance standards.
• Basic proficiency in Microsoft Excel.
• Strong attention to detail, analytical skills, and ability to meet productivity standards.

Required Certification One of the Following

• Certified Coding Specialist (CCS) through AHIMA.
• Certified Professional Biller (CPB) through AAPC.

Preferred

• Associate degree in Health Information Management, Health Information Technology, or a related field.
• Registered Health Information Technician (RHIT) certification.
• Registered Health Information Administrator (RHIA) certification.
• Experience using Solventum 360 Encompass, Epic, CloudMed, Iodine, or SmarterDx.
• Previous experience in a hospital-based inpatient coding environment.

Core Competencies

• Advanced inpatient coding and medical record abstraction skills.
• Strong understanding of coding regulations and reimbursement methodologies.
• Excellent analytical and problem-solving abilities.
• Ability to independently manage coding assignments and meet deadlines.
• Exceptional accuracy and attention to detail.
• Effective communication with physicians, clinical documentation teams, and coding leadership.
• Ability to maintain confidentiality and handle sensitive patient information.
• Commitment to professional development and continuous improvement.