About the Role
We are seeking an experienced Senior Inpatient Coder to join our Health Information Management team. In this role, you will prioritize, abstract, and accurately code high-dollar charts from acute care tertiary facilities, ensuring compliance with federal regulations, payer guidelines, and official coding standards. This position is ideal for a highly skilled coding professional with extensive inpatient experience and a strong understanding of revenue cycle processes, clinical documentation improvement (CDI), and health information workflows.
Key Responsibilities
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Review complex medical documentation from clinicians, qualified health professionals, and hospitals to assign diagnosis and procedure codes using ICD CM/PCS, CPT, and HCPCS.
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Assign codes for Present on Admission (POA), Hospital-Acquired Conditions (HACs), Core Measure Indicators, and research documentation both concurrently and post-discharge.
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Ensure correct code selection following Official Coding Guidelines, payer requirements, and compliance standards using EMR and/or Computer Assisted Coding (CAC) software.
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Collaborate with clinical staff, HIM, CDI, Patient Accounts, and Integrity teams to clarify documentation and optimize reimbursement and clinical outcomes.
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Process claim edits for all patient types and manage consecutive/combined accounts per 72-hour rules.
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Perform informal peer reviews for inpatient and outpatient coders.
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Track and analyze coding quality data to identify opportunities for education and workflow improvement.
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Maintain current knowledge of coding, reimbursement, and regulatory updates, applying critical decision-making to independently query for documentation clarification.
Required Qualifications
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Coding Certification from AAPC or AHIMA.
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Associate’s Degree in Health Information Management or a related field.
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Minimum 7 years of inpatient coding experience in an acute care tertiary facility, including exposure to revenue cycle processes, CDI, research, and health information workflows.
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Strong proficiency with EMR systems and computer-assisted coding software.
Skills & Competencies
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Advanced understanding of inpatient coding guidelines and compliance requirements.
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Excellent analytical and critical thinking skills.
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Strong collaboration and communication skills to liaise with clinicians and cross-functional teams.
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Ability to manage high-volume, high-complexity charts with accuracy and attention to detail.
Working Conditions
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Office-based environment with the ability to sit for extended periods.
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May require travel to other sites and exposure to road and weather hazards.
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Operates necessary equipment to perform coding and HIM duties.
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