Hospital Inpatient Coder

Jobtailor; Deutschland; Remote; EUR 55.000 - 75.000; Vollzeit

Zusammenfassung

Jobtailor is seeking a detail-oriented Clinical Documentation Integrity (CDI) coder in Germany to review medical records, assign ICD-10-CM/PCS codes, and determine DRG based on diagnoses and comorbidities.

You will abstract data for reporting, apply coding guidelines, and collaborate with the CDI team to drive documentation improvement while using EPIC CS-Link and other coding tools. This role emphasizes accuracy and adherence to guidelines in a hospital setting.

Qualifikationen

• High school diploma or GED required.
• Minimum 3 years’ work experience performing medical code assignment in a healthcare setting.
• Experience with ICD-10-CM and ICD-10-PCS coding guidelines.
• Knowledge of MS-DRG and APR-DRG systems.
• Familiarity with SDOH, HCC, and severity impacting conditions.
• Experience with EPIC CS-Link, HB/PB modules, and Solventum/Select Coder tools.

Aufgaben

• Review medical documentation and assign ICD-10-CM and ICD-10-PCS codes.
• Identify principal diagnoses, comorbidities, and determine DRG.
• Abstract required data elements for reporting and statistics.
• Apply industry coding requirements and assess SDOH/PSI impacts.
• Resolve complex inpatient edits and alerts per guidelines.
• Collaborate with CDI team on clinical and coding alignment.
• Identify documentation improvement opportunities and seek physician clarification.
• Enter coded information into assigned systems.

Kenntnisse

ICD-10-CM Coding

ICD-10-PCS Coding

MS-DRG Knowledge

Certified Professional Coder

Electronic Medical Systems

Ausbildung

High school diploma or GED

Tools

EPIC CS-Link

EPIC HB/PB Modules

Solventum 360Encompass

Solventum Standalone Encoder

Select Coder

Jobbeschreibung

Responsibilities

• Review medical documentation and health information and assign applicable ICD-10-CM and ICD-10-PCS codes


• Identify principal diagnoses, comorbidities/complications, present-on-admission indicators, and sequence codes to determine the appropriate DRG


• Abstract required data elements for reporting and statistical capture


• Apply industry requirements for category coding and assess impacts such as SDOH and PSI


• Resolve complex inpatient edits and alerts using current guidelines


• Communicate with Clinical Documentation Integrity team members regarding complex clinical scenarios


• Translate medical records, diagnoses, procedures, and treatment into standardized codes


• Collaborate with the CDI team to align clinical and coding approaches


• Identify documentation improvement opportunities and seek clarification from physicians


• Enter coded and abstracted information into assigned systems

Requirements

• High school diploma or GED required


• Minimum of 3 years’ work experience doing code assignment in a healthcare setting performing similar coding duties


• Registered Health Info Tech, Registered Health Info Admin, Certified Professional Coder, Certified Coding Specialist, or Certified Coding Spec Phys required upon hire


• Knowledge of ICD-10-CM and ICD-10-PCS coding


• Knowledge of Medicare Severity Diagnosis Related Groups (MS-DRG) and All Patient Refined Diagnosis Related Groups (APR-DRG)


• Knowledge of Social Determinants of Health (SDOH), Hierarchical Conditions (HCC), and severity impacting conditions


• Experience with electronic medical/health systems and coding applications such as EPIC (CS-Link), EPIC HB/PB modules, Solventum 360Encompass, Solventum Standalone Encoder, and Select Coder


• Knowledge of anatomy, physiology, and clinical practice


• Ability to apply current coding guidelines and resolve complex inpatient edits/alerts

Core Competencies

Demonstrates expertise in ICD-10-CM and ICD-10-PCS coding, with a strong understanding of MS-DRG and APR-DRG methodologies. Proficient in collaborating with clinical teams to enhance documentation and coding accuracy while applying current coding guidelines.

Highest-signal resume keywords

• ICD-10-CM Coding


• ICD-10-PCS Coding


• MS-DRG Knowledge


• Certified Professional Coder


• Electronic Medical Systems Experience

ATS Optimization Keywords

Hard Skills

• Code Assignment


• Data Abstraction


• Documentation Improvement


• Complex Edit Resolution


• Clinical Coding

Soft Skills

• Communication


• Collaboration

Certifications & Qualifications

• Registered Health Info Tech


• Registered Health Info Admin


• Certified Coding Specialist


• Certified Coding Spec Phys

Industry Keywords

• Social Determinants of Health


• Hierarchical Conditions


• Severity Impacting Conditions


• Anatomy Knowledge


• Physiology Knowledge

Tools & Technologies

• EPIC CS-Link


• EPIC HB/PB Modules


• Solventum 360Encompass


• Solventum Standalone Encoder


• Select Coder