Clinic Medical Record Coder

Cedars-Sinai; Austin (TX); Remote; USD 65,000 - 90,000; Full time

Benefits offered by this job

Paid time off

Health insurance

403(b) plan

Job summary

Cedars-Sinai is seeking an Hospital Inpatient Coder to assign ICD-10-CM and ICD-10-PCS codes by reviewing documentation and determining the principal diagnosis and comorbidities. You will identify the DRG representing the patient stay and collaborate with the CDI team to ensure complete, accurate coding.

The role involves abstracting data into the health system using EPIC CS-Link, EPIC HB/PB, Solventum, and other encoding tools, with emphasis on accuracy and adherence to guidelines.

Qualifications

• 3+ years in inpatient code assignment in healthcare required.
• Knowledge of MS-DRG and APR-DRG concepts preferred.
• Ability to abstract data and ensure accurate coding for statistics.

Responsibilities

• Assign ICD-10-CM and ICD-10-PCS codes from documentation.
• Identify principal diagnosis, comorbidities, and POA indicators.
• Determine sequencing to represent DRG for patient stay.
• Collaborate with CDI team to align clinical and coding approaches.
• Abstract data elements for reporting and statistics.

Skills

ICD-10-CM coding

ICD-10-PCS coding

DRG assignment

CDI collaboration

Education

RHIT/RHIA or similar certification

CPCT/CCS or related

Tools

EPIC (CS-Link)

EPIC HB & PB

Select Coder

Solventum 360Encompass

Job description

Align yourself with an organization that has a reputation for excellence. Cedars Sinai was awarded the National Research Corporation's Consumer Choice Award 19 years in a row for providing the highest-quality medical care in Los Angeles. We were also awarded the Advisory Board Company’s Workplace of the Year. This annual award recognizes hospitals and health systems nationwide that have outstanding levels of employee engagement. We offer an amazing benefits package that includes paid time off, health care and a 403(B). Join us! Discover why U.S. News & World Report has named us one of America's Best Hospitals.

What you will be doing in this role:

Working under the general direction of a coding supervisor, the Hospital Inpatient Coder is responsible for the assignment of ICD-10-CM and ICD-10-PCS codes by reviewing all appropriate documentation in accordance with standard coding guidelines. The Facility Inpatient Coder identifies the principal diagnosis, comorbidities/complications, present on admission indicators, and determines sequencing of codes to calculate the most appropriate DRG representing the patient stay. The role maintains knowledge of both Medicare Severity Diagnosis Related Groups (MS-DRG) and All Patient Refined Diagnosis Related Groups (APR-DRG) is required. Additionally, the incumbents maintain knowledge of appropriate capture of codes for statistical purposes such as Social Determinants of Health (SDOH), Hierarchical Conditions (HCC), and severity impacting conditions.

Reviews medical documentation/health information within various electronic medical/health system(s) and assigns applicable codes (ICD-10-CM, ICD-10-PCS) within productivity and quality standard for area(s) of assignment/specialty (Facility or Professional).

Abstracts all required data elements for reporting and statistical capture in a timely and accurate manner into the applicable system using the applications appropriate to the work assignment. This may include but not limited to: EPIC (CS-Link), EPIC HB and PB modules, Solventum 360Encompass, Solventum Standalone Encoder, Select Coder, etc.

Applies basic knowledge of industry requirements of specific category coding and the impact (SDOH, PSI).

Resolves complex inpatient edits/alerts with consistent accuracy using current guidelines within area(s) of assignment/specialty.

Communicates with Clinical Documentation Integrity Team members regarding complex clinical scenarios to ensure all relevant codes are assigned.

Focuses learning on advanced level concepts.

Translates medical records/health information including diagnoses, procedures and treatment and assigns standardized codes (International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), International Classification of Diseases, Tenth Revision, and Procedure Coding System (ICD-10-PCS) for patients receiving services within the Cedars Sinai Health System and its affiliates.

Communicates collaboratively with the Clinical Documentation Integrity (CDI) team to align both clinical and coding approaches to ensure a complete coding profile. References anatomy, physiology, and clinical practice to support code assignment and contribute to CDI discussions.

Abstracts data elements to satisfy statistical requests by the health system, medical staff, and enters all coded/abstracted information into the assigned system. Identifies opportunities for documentation improvement and seeks clarity by the physicians.

*Approved Remote States: Arizona, California, Colorado, Florida, Georgia, Minnesota, Nevada, Oregon, Texas*

Qualifications

Requirements:

• High school diploma or GED required.
• A minimum of 3 years' work experience doing code assignment in a healthcare setting performing similar coding duties required.
• Registered Health Info Tech, Registered Health Info Admin, Certified Professional Coder, Certified Coding Specialist, or Certified Coding Spec Phys required upon hire.

Why work here?

Beyond outstanding employee benefits including health and dental insurance, paid vacation, and a 403(b), we take pride in hiring the best, most passionate employees. Our accomplished staff reflects the culturally and ethnically diverse community we serve. They are proof of our commitment to creating a dynamic, inclusive environment that fuels innovation.

• paid time off, health care and a 403(B)
• health and dental insurance, paid vacation, and a 403(b)