Medical Coder

Pena4 Tech Solutions; Visakhapatnam, Hyderabad; On-site; INR 600,000 - 900,000; Full time

Job summary

Pena4 Tech Solutions is seeking an Inpatient Medical Coder to review medical records and assign accurate ICD-10-CM, ICD-10-PCS, and CPT codes for inpatient hospital services. The coder ensures compliance with regulatory guidelines and supports revenue integrity and data analytics.

The ideal candidate will have 2.5–3 years inpatient coding experience, strong knowledge of coding systems, and experience with EHRs (EPIC/Cerner/Meditech).

Qualifications

• Bachelor's degree in healthcare-related or science field.
• 2.5–3 years inpatient coding experience in acute care or similar setting.
• Strong knowledge of ICD-10-CM/ICD-10-PCS and DRG/APC assignment methodologies.
• Experience with EHRs such as EPIC, Cerner, Meditech.
• Familiarity with coding audits and CDI collaboration.
• AHIMA or AAPC certification (e.g., CCS, RHIT, RHIA or CIC).
• Ability to analyze and abstract complex medical data quickly and accurately.

Responsibilities

• Perform ICD/CPT coding for inpatient diagnoses and procedures.
• Assign DRG/APC based on documentation.
• Query physicians when documentation is unclear or incomplete.
• Adhere to AHA guidelines, CPT guidelines, and UHDDS definitions.
• Abstract codes and data entry for client requirements.
• Maintain coding quality and productivity standards.
• Participate in education sessions and ongoing training.

Skills

ICD-10-CM/ICD-10-PCS

CPT coding

MS-DRG/APR-DRG

EHR systems (EPIC/Cerner/Meditech)

HIPAA compliance

Communication with physicians

Attention to detail

3M/Tru Code encoding tools

Education

Bachelor's degree in healthcare/related field

Tools

3M

TruCode

Job description

Job Summary

The Inpatient Medical Coder is responsible for reviewing, analysing, and assigning accurate ICD-10-CM, ICD-10-PCS, and/or CPT codes to diagnoses and procedures for inpatient hospital services based on medical record documentation. The IP Coder ensures coding compliance with federal regulations and official coding guidelines to optimize reimbursement and support data integrity for reporting and analytics.

Position Purpose: The purpose of the Inpatient Medical Coder position is to ensure the accurate and timely coding of diagnoses and procedures for inpatient hospital stays using ICD-10-CM and ICD-10-PCS coding systems. This role supports appropriate reimbursement, compliance with regulatory requirements, and the integrity of clinical documentation. By translating medical records into standardized codes, the IP Coder plays a critical role in the hospital's revenue cycle, data reporting, and overall healthcare quality management.

Essential Job Requirements

Education

• A bachelor's degree, preferably in a healthcare-related or science field.

Experience

• Minimum 2.5 to 3 years of inpatient coding experience in an acute care hospital or similar healthcare setting.
• Strong working knowledge of ICD-10-CM and ICD-10-PCS coding systems.
• Experience with MS-DRG and APR-DRG assignment methodologies.
• Familiarity with medical record review processes and clinical documentation improvement (CDI) collaboration.
• Experience using electronic health records (EHRs) such as EPIC, Cerner, or Meditech.
• Previous exposure to coding audits and implementing corrective feedback (preferred).

Required Skills

• Certification: Current coding certification from AHIMA (e.g., CCS, RHIT, RHIA) or AAPC (e.g., CIC).
• Strong understanding of anatomy physiology.
• Strong understanding of medical terminology.
• Strong understanding of disease processes.
• Familiarity with official coding guidelines (AHA Coding Clinic, CMS rules).
• Ability to analyze and abstract complex medical data quickly and accurately.
• High level of attention to detail and accuracy in code assignment.
• Proficiency with coding software and encoder tools (e.g., 3M, Tru Code).
• Ability to work independently and meet productivity and quality benchmarks.
• Excellent written and verbal communication skills for physician queries and team collaboration.
• Strong time management and organizational skills in a remote or on-site environment.
• Commitment to confidentiality and HIPAA compliance.

Preferred Skills

• Working experience on multidisciplinary patient services clients (customers) is an added advantage.
• Knowledge of EPIC, 3M coding, Optum, computer-assisted coding (CAC), abstracting software, Meditech, Clintegrity 360, etc.

Physical Requirements

• Flexibility to work overtime or weekends during high-volume periods.

Position Responsibilities

• Perform ICD (International Classification of Diseases) diagnosis/procedure coding CPT (Current Procedural Terminology) coding for clients based on scope of expertise.
• Review and analyze medical records for DRG/APC assignment to accurately reflect the diagnoses and procedures documented in medical records, particularly as it relates to SOI level, ROM, POA, HAC, and PSI indicators.
• Adhere to the AHA Official Coding Guidelines, AMA CPT Guidelines, and UHDDS definitions.
• Perform abstracting and data entry of codes and abstract items as pertinent to the clients requirements.
• Query physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous, or unclear for coding purposes.
• Participate in communication concerning documentation issues to support accurate coding.
• Achieve and maintain coding quality and productivity standards for each specific account.
• Bring identified concerns to the coding manager for resolution.
• Display initiative and support continuous quality improvement efforts.
• Attend all mandatory education sessions as directed as well as tailored education sessions that have been provided based on individual skill and/or knowledge gaps.