Inpatient Coder

Inpatient Coder

FusionHCR is seeking an experienced Inpatient Coder responsible for the expert coding of inpatient medical records to support accurate reimbursement, clinical data integrity, research, utilization review, and regulatory reporting.

The Inpatient Coder will review and code complex inpatient medical records, identify coding opportunities, recommend improvements, monitor coding trends, and escalate discrepancies as appropriate. This position requires strong knowledge of inpatient coding guidelines, reimbursement methodologies, and acute-care hospital coding practices.

Education & Experience

• High school diploma or equivalent.

• Minimum of 3 years of inpatient coding experience in an acute-care hospital setting.

Required Certification

Candidates must possess at least one of the following:

• Certified Coding Specialist (CCS)

• Registered Health Information Administrator (RHIA)

• Registered Health Information Technician (RHIT)

Key Knowledge & Expertise

• ICD-10-CM/PCS, CPT, HCPCS, and ICD-9-CM code sets.

• Medicare inpatient hospital and IPPS reimbursement regulations.

• MS-DRG classification and reimbursement methodology.

• Current inpatient coding guidelines and healthcare regulations.

• Electronic Health Record (EHR) systems and healthcare technology.

• Revenue cycle workflows, including charges/charge master, code edits, auditing, denials management, and clinical documentation improvement.

• Medical terminology, anatomy and physiology, disease processes, and surgical procedures.

• Applicable healthcare laws, regulations, patient confidentiality requirements, and hospital policies.

Skills & Responsibilities

• Accurately code and abstract inpatient medical records while meeting established quality and productivity standards.

• Review medical documentation for completeness, consistency, and coding accuracy.

• Identify coding discrepancies, trends, and opportunities for improvement.

• Review coding-related denials and perform appropriate follow-up.

• Perform data collection, manipulation, retrieval, and analysis.

• Run queries and prepare technical reports.

• Utilize 3M 360 or similar integrated encoder/computer-assisted coding systems.

• Maintain strict confidentiality of patient and organizational information.

• Work independently while maintaining a high level of attention to detail and accuracy.

• Effectively communicate coding issues, findings, and recommendations to appropriate stakeholders.

• Establish and maintain effective working relationships across departments.