Medical Coder (Inpatient) - Full-time, Regular

Role Overview

The Medical Coder (IP) is responsible for accurately assigning ICD-10-CM/PCS diagnosis and procedure codes for inpatient hospital services. This role ensures coded data is complete, compliant, and supports appropriate reimbursement, quality reporting, and regulatory requirements.

• 100% REMOTE
• Position Type: W2 Regular Employment
• At least 5 years of IP PCS Coding experience, required
• CCS certificate is required.
• Schedule: Monday - Friday, full-time hours
• Shift: Regular day shift hours
• System Experience: EPIC | Power Chart | 3M | Cerner
• Start Date: Immediately
• Must complete and pass an IP coding assessment test and successfully code 5 charts.

Key Responsibilities

Medical Coding

• Review complete inpatient medical records to accurately determine the principal and secondary diagnoses, procedures, and complications
• Assign accurate ICD-10-CM and ICD-10-PCS codes for diagnoses and procedures
• Accurately sequences diagnoses and procedures
• Ensure documentation supports MS-DRG assignment and severity of illness (SOI) and risk of mortality (ROM)
• Strive to obtain the optimal DRG assignments on each medical record coded with assistance of computer system
• Apply official coding guidelines, UHDDS definitions, and payer-specific requirements
• Query providers for clarification when documentation is incomplete, inconsistent, or unclear
  • Appropriately hold accounts when more information is required for accurate code/DRG assignment
  • Contact appropriate staff, leadership or medical staff as needed
• Meet established productivity and accuracy benchmarks
  • Demonstrate a consistent level of productivity and performance
  • Code a minimum of 2 inpatient charts per hour
  • Maintain a monthly coding accuracy and DRG accuracy rate of 95% or above
• Collaborate with CDI, compliance, and billing teams to resolve coding issues
• Participate in internal audits, external audits, and education initiatives
• Works as a team member to meet department and client specific goals
• Complete all assignments in conscientious and reliable manner
• Medical coders are expected to generate revenue by performing billable hours equal to 1 (one) times annual salary

Compliance

• Ensure compliance with ICD-10-CM/PCS, MS-DRG/APR-DRG, and payer specific requirements
• AHA official coding guidelines, coding clinics, CMS and AHIMA standards of ethical coding, and other regulatory standards
• Client-specific coding guidelines, policies and procedures except when in conflict with official coding guidelines
• Maintain confidentiality and comply with HIPAA regulations

Education & Training

• Regularly reviews coding literature to stay current on new or revised coding guidelines
• Maintains appropriate certifications from AHIMA/AAPC
• Expresses interest in and pursues continuing education

Perform additional duties as assigned and assist with other tasks as requested.

Required Skills & Qualifications

Experience:

• Minimum of five (5) years of HIM and inpatient facility coding experience

Education:

• Associates degree required in Health Information Management, Healthcare Administration, other healthcare related fields, or Business Administration or Management, Bachelor’s degree preferred
• Candidates with significant relevant experience and demonstrated expertise may be considered in place of formal educational requirements.

Credentials/Certifications:

• CCS required
• Additional credentials preferred (RHIA, RHIT, CCS-P, CPC, CPMA, COC, CIC, CRC)

Skills & Knowledge:

• Advanced knowledge of medical terminology and pharmacology, ICD-10-CM/PCS coding, MS-DRGs, APR-DRGs, POAs, HACs, PSIs
• Advanced knowledge of documentation standards and improvement methodologies
• Knowledge and use of grouper and encoder systems, 3M/Nuance Clintegrity preferred
• Knowledge and use of EMR’s, Epic/Powerchart preferred
• Strong organizational, analytical and problem-solving abilities and techniques
• Client relationship and management skills
• Strong proficiency in Microsoft Office
• Ability to work independently in a remote environment

Physical Job Requirements

• Ability to travel between office and client locations if needed
• Ability to operate standard office equipment for prolonged periods (pc/laptop, phone, keyboard, mouse, monitor, printer/scanner/copier, etc.)
• Ability to perform repetitive hand and wrist motions (typing, data entry)
• Ability to sit extended periods of time, with occasional standing and walking in the office
• Ability to communicate effectively in person, by phone, and via electronic means
• Ability to lift and carry objects typically up to 15 pounds such as files or office supplies
• Ability to maintain focus in a typical office environment with moderate noise level

About Pena4

Pena4 is a global provider of healthcare, revenue cycle, and technology solutions focused on innovation and human expertise. With a presence across the USA, India, Canada, and Puerto Rico we deliver high-quality services in medical billing, coding, consulting, and integrated technology solutions. Our mission is to blend technology with human expertise to boost client outcomes and create lasting value.

Why Join Us


You will work alongside passionate teams, gain valuable skills, and help shape how Pena4 connects with clients around the world.

We believe that employee well-being is of utmost importance. We offer unmatched opportunities and rewards across the globe. Our inclusive work ethics and environment offer a range of benefits to support employees and their eligible family members, making it easier to stay healthy physically, emotionally, and financially.

Culture and Values

The Pena4 employee experience is guided by our values of integrity, customer commitment, caring about people, innovation, inclusion, and responsibility. The most fundamental reason we exist as a company is our teams' unparalleled passion for innovation. We believe that each individual, and every team, at Pena4 is central to our success. We are committed to creating an agile environment that inspires our people through professional development, cross-collaborative opportunities, and access to cutting-edge learning resources.

Limitations and Disclaimer


The above job description is meant to describe the general nature and level of work being performed; it is not intended to be construed as an exhaustive list of all responsibilities, duties and skills required for the position. This job description in no way states or implies that these are the only duties to be performed by the employee occupying this position. Employees will be required to follow any other job-related instructions and to perform other job-related duties requested by their supervisor in compliance with Federal and State Laws. Requirements are representative of minimum levels of knowledge, skills and/or abilities. To perform this job successfully, the employee must possess the abilities or aptitudes to perform each duty proficiently. Continued employment remains on an “at-will” basis.

All job requirements are subject to possible modification to reasonably accommodate individuals with disabilities. Some requirements may exclude individuals who pose a direct threat or significant risk to the health and safety of themselves or other employees.

Monday - Friday
40 hours per week, standard business hours