Certified Medical Records Coder-Inpatient (Riverside)

DaMar Staffing; Riverside (CA); On-site; USD 60,000 - 90,000; Full time

Job summary

Riverside University Health System's Medical Records Department in Riverside, CA seeks a Certified Medical Records Coder - Inpatient to perform complex coding and abstracting per ICD-CM, PCS and CPT guidelines. The role requires knowledge of DRG assignment and IPPS, with collaboration with Clinical Documentation Improvement Team and physicians.

A hybrid work schedule may be offered; pre-employment checks apply.

Qualifications

• Four years as a Certified Medical Records Coder - Outpatient with the County of Riverside.
• Two years inpatient medical record coding experience in an acute care setting using ICD-CM, PCS and CPT.
• Knowledge of ICD-CM, PCS, CPT and DRG assignment; anatomy and physiology basics.
• Ability to use Windows-based software, coding software and abstract packages; communicate clearly.

Responsibilities

• Code medical record entries pertaining to diagnoses and procedures according to ICD-CM, PCS and CPT; enter information into the designated system.
• Abstract ADT data: admissions, discharges, transfers; note surgery types and anesthesia.
• Query physicians for correct codes; coordinate with physicians and staff as needed.
• Collaborate with CDS team when documentation is unclear to support code assignments.
• Assist and provide coding training to inpatient/outpatient staff as needed.

Skills

ICD-CM

PCS

CPT

DRG assignment

Tools

Windows

Coding software

Encoder

Job description

Certified Medical Records Coder Position

The County of Riverside - Riverside University Health System - Medical Records Department is seeking to fill a Certified Medical Records Coder position located in Riverside. Under general supervision, performs advanced coding and abstracting of inpatient medical record entries according to the most current edition of International Classification of Diseases - Clinical Modification System (ICD-CM), Procedure Coding System (PCS) and Current Procedural Terminology (CPT); performs other related duties as required. The Certified Medical Records Coder - Inpatient classification performs the most complex coding and abstracting of a high volume of patient records in the Medical Records Department and reports to an appropriate supervisory or manager level position. The Certified Medical Records Coder - Inpatient is distinguished from the Certified Medical Records Coder - Outpatient in that the latter does not require an extensive knowledge of complex code and Diagnosis Related Group (DRG) assignment. Incumbents are expected to be familiar with the Inpatient Prospective Payment System (IPPS), inpatient coding guidelines, and be able to work closely with the Clinical Documentation Team as well as physicians. Candidates with acute hospital experience are encouraged to apply. Applicants will be tested as part of the hiring process.

Work Location: 7898 Mission Grove Pkwy Ste 200 Riverside, CA. 92508

Work Schedule

This position offers a hybrid work schedule, which may include working both in the office and remotely, at the department's discretion. The selected candidate must maintain both the productivity and accuracy standards established by the department. Employees may be required to work swing shifts, weekends, and some holidays depending on operational needs.

Standard Schedule Options

• Monday – Friday (5/80 schedule)
• Day Shift
• Typical hours: o8:00 AM – 4:30 PM, or o8:30 AM – 6:00 PM

Alternative Schedule Options

• Sunday – Thursday
• Tuesday – Saturday

Schedules may vary based on departmental needs. Employees may indicate their preferred schedule, when available.

Weekends: Weekend shifts may be available but are not currently required.

Holidays: Employees typically work 3–4 holidays per year, assigned through a rotation or draw system.

Riverside University Health System provides a wide range of primary and specialty care services across 13 Community Health Centers (CHCs) throughout Riverside County. As federally qualified health centers, the CHCs operate on a sliding fee scale to ensure that some of the county's most vulnerable populations receive the care they need. Whether it's preventive care, chronic disease management, Express Care, Mobile Health, or integrated specialty and behavioral health services, our teams are made up of dedicated healthcare professionals who are passionate about making a difference. If you're committed to delivering compassionate care and eager to join a team that truly values community, connection, and making a meaningful difference, RUHS is the place for you!

Examples of Essential DutiesExamples of Essential Duties

• Code medical record entries pertaining to diagnoses and procedures according to the most current edition of ICD-CM, and when applicable PCS and CPT; enter information into the designated computer system.
• Abstract patient information such as Admission, Discharge and Transfer (ADT), type of surgery, type of anesthesia, length of stay, and assist clinical providers as needed.
• Query physicians when assistance is needed for proper identification of codes for diagnoses or procedures; communicate with physicians and others involved in the treatment of patients as needed.
• Work with Clinical Documentation Improvement Team when there are conflicting diagnoses, ambiguous, inconsistent, missing, and unclear clinical documentation by the physician to support code assignment.
• Assist and provide coding training to Certified Medical Record Coder - Outpatient as needed.

Minimum QualificationsRecruiting Guidelines

• OPTION I Experience: Four years as a Certified Medical Records Coder - Outpatient with the County of Riverside.
• OPTION II Experience: Two years of inpatient medical record coding experience in an acute care setting using ICD-CM, PCS and CPT coding. (Experience must have been within the last four years.)
• ALL OPTIONS Knowledge of : ICD-CM, PCS and CPT classification coding systems and DRG assignment; the fundamentals of anatomy, physiology and the study of diseases; standard clerical office procedures and equipment, including Windows-based software use.
• Ability to: Utilize the ICD-CM classification system to code medical record entries either by use of coding books or encoder product; abstract pertinent information from medical records; follow oral and written instructions; operate PC with Windows software, coding software and abstract package; effectively communicate technical information to medical and administrative personnel; maintain effective working relationships with others.

License/Certificate

Possession of current valid certification as a Certified Coding Specialist (CCS), Certified Professional Coder (CPC), Registered Health Information Administrator (RHIA) or a Registered Health Information Technician (RHIT) issued by American Health Information Management Association, or Certified Professional Coder-Hospital (CPC-H) issued by the American Academy of Professional Coders.

Pre-Employment

All employment offers are contingent upon successful completion of both a pre-employment physical exam, including a drug/alcohol test, and a criminal background investigation, which involves fingerprinting. (A felony or misdemeanor conviction may disqualify the applicant from County employment.)

Probationary Period

As an Approved Local Merit System, all County of Riverside employees, except those serving "At Will," are subject to the probationary period provisions as specified in the applicable Memorandum of Understanding, County Resolution, or Salary Ordinance.

Temporary and Per Diem

Temporary and Per Diem employees serve at the pleasure of the agency/department head.