Coder Inpatient

A coder with 2+ years of experience in coding inpatient cases for an acute care facility in the specialties of cardiothoracic (bypass/TAVRs) cardiology, neurology, spinal, orthopedics, general medicine and general surgery. Must be experienced with Epic and 3M. Must hold an active CCS, RHIT or RHIA credential. Schedule expectations are 8 hours Monday through Friday between 8a and 5p PST. There is some flexibility, but the majority of the shift must be worked within this timeframe. FULL TIME ONLY. 

Summary/Objective 
Under limited supervision the Coder Inpatient reviews medical records and performs coding on all diagnoses, procedures, and  DRG.  The Coder Inpatient uses the most accurate codes for reimbursement purposes, research, epidemiology, statistical analysis outcomes, financial and strategic planning, evaluation of quality of care, and communication to support the patient’s treatment.  The Coder Inpatient will be charged with maintaining the confidentiality of patient records and procedures. 

Essential Job Functions 

• Responsible for abstracting, coding, sequencing and interpreting the clinical information from inpatient, outpatient, emergency department, pro fee and clinical medical records. 
• Responsible for the assignment of correct principal diagnoses, secondary diagnoses and principal procedure and secondary procedure codes with attention to accurate sequencing. 
• Utilizes technical coding principals and DRG/APC reimbursement expertise to assign appropriate codes. 
• Abstracts and codes pertinent medical data into multiple software programs and/or encoders.  Follows official coding guidelines to review and analyze health records. 
• Maintains compliance with both external regulatory and accreditation requirements, and with State and Federal regulations. 
• Extracts pertinent data from the patient’s health record, and determines appropriate coding for reports and billing documents. 
• Identifies codes for reporting medical services, procedures performed by physicians.  Enters codes into various computer systems dependent upon the various clients. 
• Track and document productivity in specified systems, maintain productivity levels as defined by the client. 
• Maintain 95% quality rating 
• Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance. 

Key Success Indicators/Attributes 

• Ability to prioritize and multi-task in a fast-paced, changing environment. 
• Demonstrate ability to work in all work types and specialties. 
• Demonstrate ability to self-motivate, set goals, and meet deadlines. 
• Demonstrate leadership, mentoring, and interpersonal skills. 
• Demonstrate excellent presentation, verbal and written communication skills. 
• Ability to develop and maintain relationships with key business partners by building personal credibility and trust. 
• Maintain courteous and professional working relationships with employees at all levels of the organization. 
• Demonstrate excellent analytical, critical thinking and problem solving skills. 
• Skill in operating a personal computer and utilizing a variety of software applications. 
• Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes. 
• Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation. 

Supervisory Responsibility 

No 

Work Environment 

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones. 

Physical Demands 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. 

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear.  The employee must occasionally lift or move up to 25 pounds.  Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus. 

Position Type/Expected Hours of Work 

This is a full-time position.  Days and hours of work are generally Monday through Friday, 8:00 a.m. to 5 p.m.  This position occasionally requires long hours and weekend work. 

Travel 

Minimal travel required; up to 5% 

Required Education and Experience 

Successful completion of an AAPC or AHIMA-approved Coding Certificate Program and a minimum of two to four years of current production coding experience in both acute care and profee.   

Preferred Education and Experience 

N/A 

Additional Eligibility Qualifications 

Must have the following certificates and/or licenses: RHIA, RHIT, CCS. 

Other Duties 

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.  Duties, responsibilities and activities may change at any time with or without notice.  Employee may perform other duties as assigned. 

1. 2+ years of experience coding inpatient medical and surgical cases
2. Epic and 3M experience
3. CCS, RHIT or RHIA
4. Able to work 8a-5p PST
5. Good verbal and written communication skills
6. Able to achieve 2 CPH productivity within 4 weeks and maintain after
7. Able to maintain 95% coding accuracy
8. Able to pick up new workflows and technology easily