Hospital Inpatient Coder Certified - FT - Day - HIM Facility Coding Lawrenceville NJ

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region.

Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization. As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates.

The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range:

$28.70 - $37.32

Scheduled Weekly Hours:

40

Position Overview

Reviews and analyzes inpatient medical record documentation to assign accurate and compliant ICD-10-CM diagnosis codes, ICD-10-PCS procedure codes, and MS-DRG/APR-DRG groupings. Ensures proper reimbursement, supports quality reporting, and maintains compliance with official coding guidelines, payer regulations, and organizational policies. works independently while collaborating with clinicians, CDI, and revenue cycle teams as needed.

MINIMUM REQUIREMENTS
Education:    High school diploma or equivalent. Certified Coding Specialist (CCS) certification.
Experience:    Previous hospital coding experience.
Other Credentials:    CCS
Knowledge and Skills:    Possesses excellent organizational, interpersonal, verbal, and written communication skills. Has vigilance and keen attention to detail. Possesses proper phone and email etiquette for frequent hospital and private provider exchanges. Excellent time management to meet deadlines and productivity targets. Intermediate computer skills
Special Training:    Thorough knowledge of medical terminology, anatomy, and physiology. Understanding of ICD-10-CM, ICD-10-PCS. Knowledge and experience using an encoder, and EMR required.
Mental, Behavioral and Emotional Abilities:    Ability to work independently in a remote environment. Ability to work under pressure. Ability to work in a fast-paced environment with ability to meet quality and productivity standards. Ability to interact effectively with other staff members to complete certain aspects of job.
Usual Work Day:    8 Hours  
Reporting Relationships
Does this position formally supervise employees? No

If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS
Reviews complete inpatient medical records, including physician notes, operative reports, consultations, imaging, lab results, and discharge summaries.
Assigns and properly sequences accurate ICD-10-CM diagnosis and ICD-10-PCS procedure codes in accordance with Official Coding Guidelines, UHDDS definitions, Coding Clinic guidance and CMS to a full range of inpatient services including cases with a high complexity level.
Assigns correct and optimal DRGs (MS-DRG/APR-DRG).
Ensures accurate capture of Major Comorbid Conditions (MCC)/Comorbid Conditions (CC), Present on Admission (POA) indicators, Hospital-Acquired Conditions (HACs), Patient Safety Indicators (PSIs), Severity of Illness (SOI) and Risk of Mortality (ROM).
Issues compliant physician queries when documentation is incomplete, ambiguous, or inconsistent. Identifies documentation gaps and escalate when clarification is needed.
Resolves coding edits, queries, and discrepancies in a timely and compliant manner.
Participates in internal and external audits; assist in implementing corrective action plans.
Collaborates with Clinical Documentation Improvement (CDI) to ensure complete documentation and optimal DRG assignment.
Supports coding leadership by identifying documentation improvement opportunities and workflow challenges.
Meets or exceeds departmental accuracy and productivity standards.
Codes inpatient encounters efficiently to support timely billing and reduce DNFB. Assists with reviewing accounts held for coding-related issues.
Maintains required coding credentials (CCS, RHIT, RHIA).
Stays current with all annual ICD-10-CM/PCS updates, DRG changes, and regulatory updates.
Participates in continuing education, team meetings, and training