Inpatient Coder

Job Responsibilities:

• Assign ICD‐10‐CM and ICD‐10‐PCS codes to inpatient diagnoses and procedures, ensuring accurate MS‐DRG or APR‐DRG grouping in accordance with official guidelines and internal policies.

• Complete the appropriate number of coded records based on departmental productivity standards and accuracy requirements.

• Abstract key clinical and demographic information from patient records to support billing, quality reporting, and regulatory compliance.

• Utilize computer‐assisted coding (CAC) tools, encoders, and official coding references to support consistent and accurate code selection.

• Initiate physician queries when documentation is incomplete, ambiguous, or unclear to ensure accurate code assignment and clarify clinical intent.

• Collaborate with Clinical Documentation Improvement (CDI) professionals to enhance documentation quality and identify areas for physician education.

• Remain current with updates to coding guidelines, reimbursement requirements, and regulatory standards impacting inpatient coding.

• Maintain patient confidentiality and comply with medico‐legal standards, including record amendment procedures and release of information policies.

Position Qualifications:

Minimum Required:

• RHIA certification with a Bachelor's Degree in HIM; OR RHIT certification with an Associate's Degree in HIM; OR CCS certification. RHIT credentials must be received within 6 months of start date.

• CCS credentials must be received within one year of start date.

• Six months of coding experience.

Preferred:

• Two years' experience with inpatient coding.

• Experience with encoding systems.

Work Environment

• All work is performed in an office where employees utilize their own workspace, however are in close quarters with other co‐workers. Frequent interruptions often take place in responding to customer requests. The office is air conditioned as well as heated.

Age of Patients Served

• Not Applicable

HIPAA Roles‐Based Access to Patient Information

• All ‐ Access to patient information, including restricted information ‐ Level 4