Coder - Inpatient

Rochester Regional Health; United States; Remote; USD 30,000 - 45,000; Full time

Job summary

Rochester Regional Health is seeking an Inpatient Coder to review clinical documentation and assign ICD-10-CM and ICD-10-PCS codes for billing, reporting, research, and regulatory compliance. This role emphasizes reimbursement accuracy and adherence to AHIMA guidelines.

The position supports resolving billing edits and improving documentation quality, with a focus on high coding accuracy and compliant DRG assignment. Remote work is available, with a M-F schedule and 7:00 AM - 3:30 PM shift.

Qualifications

• AS in Health Information Management or equivalent.
• Minimum 2 years of progressive hospital coding experience preferred.
• AHIMA guidelines and RRH policies must be followed.
• For Homecare: HCS-D certification within 16 months of hire if applicable.

Responsibilities

• Reviews inpatient medical records and assigns diagnosis and procedure codes using ICD-10-CM and ICD-10-PCS.
• Adheres to AHIMA ethical coding standards, official coding guidelines, and RRH/HIM policies and procedures.
• Meets departmental productivity standards while maintaining 95% coding accuracy.
• Utilizes Care Connect, UDS, and Clintegrity systems for coding and DRG assignment.
• Formulates compliant physician coding queries when documentation is inadequate or unclear.
• Accurately enters and updates coding data, including POA indicators and discharge disposition.
• Resolves workflow edits, billing errors, and coding-related claim issues promptly.
• Supports physicians and clinical quality staff with documentation improvement and coding reimbursement.

Skills

ICD-10-CM coding

ICD-10-PCS coding

AHIMA guidelines

Education

AS Health Information Management

Tools

Care Connect

UDS

Clintegrity

Job description

JOB TITLE: Coder - Inpatient

STATUS: Full-Time

LOCATION: Riedman- Remote

SCHEDULE: M-F; 7:00 AM - 3:30 PM

SUMMARY

Review clinical documentation and diagnostic results to extract data and apply appropriate ICD-10-CM and ICD-10-PCS codes for billing, internal and external reporting, research, and regulatory compliance. Demonstrate knowledge of reimbursement methodologies and apply these to assigned charts to optimize reimbursement and/or resolve regulatory edits. Resolve error reports associated with billing process, identify and report error patterns, and, when necessary, assist in design and implementation of workflow changes to reduce billing errors

RESPONSIBILITIES

• Reviews inpatient medical records and assigns diagnosis and procedure codes using ICD-10-CM and ICD-10-PCS.
• Adheres to AHIMA ethical coding standards, official coding guidelines, and RRH/HIM policies and procedures.
• Meets departmental productivity standards while maintaining 95% coding accuracy.
• Utilizes Care Connect, UDS, and Clintegrity systems for coding and DRG assignment.
• Formulates compliant physician coding queries when documentation is inadequate, ambiguous, or unclear.
• Accurately enters and updates coding data, including POA indicators, point of origin, and discharge disposition.
• Resolves workflow edits, billing errors, and coding-related claim issues in a timely manner.
• Supports physicians and clinical quality staff with documentation improvement, coding reimbursement, and quality review processes.

MINIMUM QUALIFICATIONS/REQUIRED LICENSURE

One of the following certifications is required:

• Applicable advance coding certification credential includes: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician Based (CCS-P), Certified Professional Coder (CPC), Certified Professional Coder Hospital Based (CPC-H), Certified Medical Coder (CMC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Professional Coder Apprentice CPC-A, or a specialty coding certification.
• Candidate with Associate degree from an accredited American Health Information Management Association (AHIMA) are required to sit for the Registered Health Information Technician (RHIT) exam within 1 year of hire
• At least 2 years of progressive coding experience in a hospital or multi-specialty physician practice setting preferred.
• For HOMECARE: Homecare Diagnosis Coding Specialist (HCS-D) certification required within 16 months of hire.

Grandfather Clause

• If hired on or before September 30, 2018, 2 years of relevant work experience and one of the following coding certification credentials: Certified Coding Specialist (CCS), Certified Coding Specialist - Physician Based (CCS-P), Certified Professional Coder (CPC), Certified Professional Coder - Hospital Based (CPC-H), Certified Medical Coder (CMC), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), or a specialty coding certification and Associate's degree in Health Information Management are required.

EDUCATION

AS: Health Information Management (Required)

LICENSES / CERTIFICATIONS

PHYSICAL REQUIREMENTS

Sedentary - Sedentary roles are primarily office-based and require prolonged sitting (67-100% of the workday) with minimal physical effort and lifting limited to under 10 lbs. Fine motor skills are necessary for computer work, writing, and telephone use, supported by clear visual and auditory ability. Cognitive and emotional demands are high due to extended concentration, frequent interruptions, independent decision-making, and information processing. Although physical exposure is low, administrative areas within healthcare environments may occasionally involve contact with infectious agents. Some roles may require flexible hours, TB screening, or a valid driver’s license.

For disease specific care programs refer to the program specific requirements of the department for further specifications on experience and educational expectations, including continuing education requirements.

Any physical requirements reported by a prospective employee and/or employee’s physician or delegate will be considered for accommodations.

PAY RANGE

$22.00 - $32.50

CITY

Rochester

POSTAL CODE

14617

The posted pay range is a good faith representation of potential base pay for this position. It may be modified in the future and eligible for additional pay components. Individual annual salaries/hourly rates could vary based on position details and FTE. Pay is determined by considering factors including, but not limited to, experience, relevant qualifications, specialty, internal equity, locations, and contracts.

Rochester Regional Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, creed, religion, sex (including pregnancy, childbirth, and related medical conditions), sexual orientation, gender identity or expression, national origin, age, disability, predisposing genetic characteristics, marital or familial status, military or veteran status, citizenship or immigration status, or any other characteristic protected by federal, state, or local law.