Job Description:
• 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 escalates when clarification is needed
• Resolves coding edits, queries, and discrepancies in a timely and compliant manner
• Participates in internal and external audits; assists 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 sessions
• Adapts to changing department demands required to maintain a high level of performance
• Performs other duties as assigned
Requirements:
• High school diploma or equivalent
• Certified Coding Specialist (CCS) certification
• Previous hospital coding experience
• 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
• 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.
Benefits:
• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA) - Healthcare FSA - Dependent Care FSA
• Retirement Savings and Investment Plan
• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
• Disability Benefits – Long Term Disability (LTD)
• Disability Benefits – Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance - Voluntary Life Spouse - Voluntary Life Employee - Voluntary Life Child
• Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program