Inpatient Coder

Inpatient Coder

The Inpatient Coder is responsible for accurately reviewing, analyzing, and assigning ICD-10-CM/PCS/CPT diagnostic and procedure codes for all inpatient and observation encounters to ensure the integrity of the patient medical record and support optimal reimbursement. This role ensures coding compliance with regulatory and organizational guidelines, including CMS, UHDDS, and official coding guidelines. The Inpatient Coder collaborates with providers, clinical documentation improvement specialists, and other HIM staff to resolve documentation issues and promote complete, accurate, and timely coding.

Minimum Qualifications

• Previous inpatient coding experience preferred.
• Bachelor's degree or Associate's degree in Health Information Management or related field required. An equivalent combination of education and/or work experience may be considered in lieu of required degree.
• CCS, CPC, RHIT, RHIA, or equivalent certification required within six months of hire or placement.
• Thorough understanding of ICD-10-CM/PCS/CPT coding systems, DRG assignment, and coding compliance guidelines.
• Knowledge of OPPS, APCs, and NCCI edits.
• Strong working knowledge of medical terminology, anatomy, physiology, and pathophysiology.
• Ability to interpret clinical documentation and identify incomplete or unclear information.
• Proficiency in electronic health records (EHR), encoder software, and related HIM applications.
• Strong analytical skills, attention to detail, and the ability to work independently with minimal supervision.
• Strong communication and interpersonal skills.