Job Title: Inpatient Coder
Location: Remote or Onsite
Department: Medical Coding
FLSA Status: Full Time, Non-Exempt
Review the medical record to assure specificity of diagnoses, procedures and appropriate/optimal reimbursement for hospital and/or professional charges. Abstract information from medical records following established methods and procedures.
Duties and responsibilities
- Assign ICD10 CM Diagnosis Codes and ICD 10 PCS Procedure Codes for assigned accounts.
- Select and sequence principal and secondary diagnosis and procedure codes.
- Assign appropriate DRG.
- Review the medical record and all applicable documentation to determine the appropriate codes to assign for the services and diagnoses.
- Be knowledgeable of billing and coding requirements for governmental guidelines and private insurance payers.
- Abstract statistical data from the patient record and enter information following the facility guidelines.
- Utilize coding resources along with any other applicable reference material available to ensure accuracy in coding for all of the assigned services.
- Review documentation of various providers to determine accurate coding for all medical services and surgical procedures from available medical records within electronic medical records.
- If the diagnosis is unclear prepare and assign queries following the facility guidelines for the query process.
- Determine all appropriate diagnoses and assign the most specific ICD-10 code.
- Assist other departments in coding and reimbursement issues.
- Follow all HIPAA regulations and uphold a higher standard around privacy requirements.
- Develop trusted relationships with the client contacts and other team members around the globe.
- Adhere to all internal competencies, behaviors, policies and procedures to ensure efficient work processes.
- Completes all assigned work in a timely manner based on internal, client and/or payer standards.
- Maintain at least a 98% accuracy rate at all times.
- Maintain productivity standards, tracking and deadlines.
- Maintain and complete accurate productivity and tracking logs.
- Keep all equipment updated and active on the internet.
- Comply with established facility policies and procedures.
- Other duties as deemed necessary by management
Education and Experience
- At least 2 years of experience Inpatient Coding
- Credentials necessary (one of the following):
- -RHIT,RHIA CIC,CCS