Sr. Medical Coder

Pena4 Tech Solutions; Visakhapatnam, Hyderabad; On-site; INR 800,000 - 1,200,000; Full time

Job summary

Pena4 Tech Solutions is seeking an experienced inpatient coding professional to perform ICD and CPT coding for healthcare clients. You will review records for DRG/APC assignment, ensuring accuracy and adherence to coding guidelines.

The role requires 4–6 years in inpatient coding, with AHIMA or AAPC certification, and strong knowledge of ICD-10-CM/PCS. EHR experience with EPIC/Cerner/Meditech is preferred, along with the ability to work independently and maintain confidentiality.

Qualifications

• 4–6 years of inpatient coding experience in at least three acute care hospitals.
• Strong knowledge of ICD-10-CM/PCS and DRG assignment.
• Experience with medical record review and CDI collaboration.
• Experience with EHRs such as EPIC, Cerner, or Meditech; exposure to coding audits.
• Ability to work independently and maintain confidentiality while meeting productivity/quality benchmarks.

Responsibilities

• Perform ICD and CPT coding for clients based on scope of expertise.
• Review medical records for DRG/APC assignment to reflect diagnoses and procedures.
• Adhere to AHA Official Coding Guidelines, AMA CPT Guidelines, and UHDDS definitions.
• Abstract codes and entries per client requirements.
• Query physicians when documentation is inadequate or ambiguous for coding.
• Participate in communication about documentation issues to support accurate coding.
• Achieve and maintain coding quality and productivity for each account.
• Raise concerns to coding manager for resolution.
• Attend mandatory and tailored education sessions.

Skills

ICD-10-CM/PCS

Physician query handling

Medical terminology

Data abstraction & accuracy

EHR knowledge (EPIC, Cerner, Meditech)

Education

AHIMA/AAPC coding certification

Tools

3M Encoder

TruCode

EPIC

Cerner

Meditech

Job description

Requirements

• Education: A bachelor's degree, preferably in a healthcare-related or science field.
• Experience: Minimum 4 to 6 years of exclusive inpatient coding experience in a minimum of 3 acute care hospitals or similar healthcare settings. Strong grip on the physician query process. 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 Medical terminology Disease processes 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 with 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