Coder Inpatient

Scope:

Inpatient coder with a minimum of 3 years of recent experience in a trauma level 1 academic acute care setting.  The role will code both medical and surgical cases for all acute care specialties (cardio, neuro, orthro, pulm, gen med, gen surg, etc.) as well as OB and psyche. Must be experienced with Epic and 3M. The role will be responsible for sending provider queries using Epic templates. Production expectation is 2 charts per hour. Quality expectation is 95% accuracy in all coding (DRG, Pdx, PCS, SOI, ROM, etc.). For initial training the schedule will be 8a-4:30p MST.  After training the schedule is much more flexible, evenings and weekends are available if desired. 

Summary/Objective 
Under limited supervision the Coder Inpatient reviews medical records and performs coding on all diagnoses, procedures, and  DRG.  The Coder Inpatient uses the most accurate codes for reimbursement purposes, research, epidemiology, statistical analysis outcomes, financial and strategic planning, evaluation of quality of care, and communication to support the patient’s treatment.  The Coder Inpatient will be charged with maintaining the confidentiality of patient records and procedures. 

 

Essential Job Functions 

Responsible for abstracting, coding, sequencing and interpreting the clinical information from inpatient, outpatient, emergency department, pro fee and clinical medical records. 

Responsible for the assignment of correct principal diagnoses, secondary diagnoses and principal procedure and secondary procedure codes with attention to accurate sequencing. 

Utilizes technical coding principals and DRG/APC reimbursement expertise to assign appropriate codes. 

Abstracts and codes pertinent medical data into multiple software programs and/or encoders.  Follows official coding guidelines to review and analyze health records. 

Maintains compliance with both external regulatory and accreditation requirements, and with State and Federal regulations. 

Extracts pertinent data from the patient’s health record, and determines appropriate coding for reports and billing documents. 

Identifies codes for reporting medical services, procedures performed by physicians.  Enters codes into various computer systems dependent upon the various clients. 

Track and document productivity in specified systems, maintain productivity levels as defined by the client. 

Maintain 95% quality rating 

Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance. 

 

 

Key Success Indicators/Attributes 

Ability to prioritize and multi-task in a fast-paced, changing environment. 

Demonstrate ability to work in all work types and specialties. 

Demonstrate ability to self-motivate, set goals, and meet deadlines. 

Demonstrate leadership, mentoring, and interpersonal skills. 

Demonstrate excellent presentation, verbal and written communication skills. 

Ability to develop and maintain relationships with key business partners by building personal credibility and trust. 

Maintain courteous and professional working relationships with employees at all levels of the organization. 

Demonstrate excellent analytical, critical thinking and problem solving skills. 

Skill in operating a personal computer and utilizing a variety of software applications. 

Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes. 

Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation. 

 

Supervisory Responsibility 

No 

 

Work Environment 

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones. 

 

 

Physical Demands 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. 

 

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear.  The employee must occasionally lift or move up to 25 pounds.  Specific vision abilities required by the job include close vision, distance visi