Health Information Management Inpatient Coder

About Prisma Health

At Prisma Health, we inspire health, serve with compassion, and strive to make a difference in the communities we serve. Join a team dedicated to transforming healthcare through excellence, collaboration, and innovation.

Position Overview

We are seeking a highly skilled Inpatient Coder to join our Health Information Management team. The ideal candidate will have experience coding complex inpatient cases, major traumas, and Neonatal Intensive Care Unit (NICU) records, accurately applying ICD, ICD-PCS, and DRG coding guidelines. This role is critical to ensuring accurate documentation, reimbursement, compliance, and quality reporting.

Key Responsibilities

• Apply ICD and ICD-PCS codes to inpatient records, including major traumas and NICU cases.

• Verify DRG assignments, MCC/CCs, Hospital-Acquired Conditions (HACs), and Patient Safety Indicators (PSIs) to reflect clinical documentation accurately.

• Assign principal diagnoses with correct POA indicators and risk adjustment sequencing per established guidelines.

• Review daily work queues, prioritize charts, and follow up on on-hold accounts for final coding.

• Initiate and respond to physician queries for unclear or ambiguous documentation following AHIMA standards.

• Adhere to departmental standards for productivity and coding accuracy.

• Identify and trend coding issues, escalating concerns to coding leadership.

• Participate in onsite, remote, and external training workshops; collaborate with CDI, PFS, and Quality teams.

• Demonstrate proficiency with electronic medical records, 3M or Encoder software, and clinical documentation systems.

• Consult and collaborate with clinical documentation specialists on coding and documentation practices.

• Perform additional duties as assigned.

Minimum Qualifications

• Certification Program: Associate Degree or Coding Certificate through AHIMA or other approved coding program.

• Experience: Minimum 3 years of coding experience in an acute care or ambulatory setting, with inpatient coding expertise.

• Credentials: One or more of the following: RHIT, RHIA, CCS, CIC, or other approved coding certification.

• Knowledge:

  • Medical terminology, anatomy, physiology, pathophysiology, and pharmacology.

  • MS-DRG prospective payment system and severity coding guidelines.

  • Electronic medical record systems; EPIC experience preferred.

• Ability to concentrate for extended periods, work independently, and make sound decisions.

Work Environment

• Corporate setting

• Day shift

• Collaborative, team-focused environment