Health Information Management Coder Senior - Coding

CHILDREN'S HOSPITAL OF SAN ANTONIO; Irving (TX); Remote; USD 65,000 - 90,000; Full time

Job summary

CHILDREN'S HOSPITAL OF SAN ANTONIO is seeking an Inpatient Coding Specialist to maintain high-quality ICD-10-CM/PCS coding for inpatient encounters. The role requires reviewing clinical documentation, ensuring a 95% accuracy rate, and abstracting data into CHRISTUS Health EMR systems.

Collaboration with HIM specialists and leadership is essential. Responsibilities include coding, data extraction, validity checks, and audits, with strong communication and independent remote work capabilities.

Qualifications

• 3–5 years of inpatient coding experience in an acute care setting.
• RHIA/RHIT/CCS/CCA certifications listed (AHIMA) are preferred.

Responsibilities

• Assign codes for diagnoses, treatments and procedures according to ICD-10-CM/PCS guidelines.
• Extracts and abstracts required information from source documentation for EHR entry.
• Validates admit orders and discharge dispositions.
• Works from assigned coding queue and finalizes accounts promptly.
• Meets or exceeds 95% accuracy and productivity standards.
• Queries providers for missing or unclear documentation with HIM/CDI teams.
• Engages in internal/external audit discussions and cross-functional collaboration.

Skills

Strong written and verbal沟通 skills

Independent remote work

Leadership competency (OneCHRISTUS)

Education

High school diploma or equivalent

Health Informatics/Health Information Management degree or AHIMA coding certificate (preferred)

Tools

Epic

Meditech

3M/360

OneContent

Microsoft Office

Teams

Outlook

OneNote

Job description

Inpatient Coding Specialist

Responsible for maintaining current and high-quality ICD-10-CM/PCS coding for all Inpatient diagnoses and procedural occurrences, through the review of clinical documentation and diagnostic results, with a consistent coding accuracy rate of 95% or better. Coder will accurately abstract data into any and all appropriate CHRISTUS Health electronic medical record systems, verifying accurate patient dispositions and physician data, following the Official ICD-10-CM and ICD-10-PCS Guidelines for Coding and Reporting. Inpatient coding is applicable towards all regional Inpatient encounters.

Coder will work collaboratively with various CHRISTUS Health HIM and Clinical Documentation Specialists to ensure accurate and complete physician documentation to support accurate billing and reduce denials. Coder will also assist in other areas of the department, as requested by leadership. Coder will report directly to their Regional Coding Manager, with additional leadership from the Director of Coding Operations and System HIM Director.

Responsibilities:

• Meets expectations of the applicable OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Assign codes for diagnoses, treatments and procedures according to the ICD-10-CM/PCS Official Guidelines for Coding and Reporting through review of coding critical documentation, to generate appropriate MS/APR DRG.
• Extracts and abstracts required information from source documentation, to be entered into appropriate CHRISTUS Health electronic medical record system.
• Validates admit orders and discharge dispositions.
• Works from assigned coding queue, completing and re-assigning accounts correctly.
• Manages accounts on ABS Hold or through Epic WQs using account activities, finalizing accounts when corrections have been made, in a timely manner.
• Meets or exceeds an accuracy rate of 95%.
• Meets or exceeds the designated CHRISTUS Health Productivity standard per chart type.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA).
• Assists in implementing solutions to reduce backend-errors.
• Identifies and appropriately reports all hospital-acquired conditions (HAC).
• Expertly queries providers for missing or unclear documentation, by working with the HIM department and Clinical Documentation Improvement Specialists.
• Participates in both internal and external audit discussions.
• Strong written and verbal communication skills.
• Demonstrated proficiency in use of multiple technologies and comfort level with virtual applications and electronic medical record applications such as Epic, Meditech, 3M/360, OneContent, Microsoft Office, Teams, Outlook, OneNote, etc.
• Able to work independently in a remote setting, with little supervision.
• All other work duties as assigned by Manager.

Job Requirements:

Education/Skills

• High school Diploma or equivalent years of experience required.
• Completion of Accredited Baccalaureate Health Informatics or Health Information Management or an AHIMA approved Coding Certificate Program, preferred.

Experience

• 3-5 years of Inpatient coding experience in an acute care setting preferred.

Licenses, Registrations, or Certifications

• Registered Health Information Administrator (RHIA) (AHIMA)
• Registered Health Information Technician (RHIT) (AHIMA)
• Certified Coding Specialist (CCS) (AHIMA)
• Certified Coding Associate (CCA) (AHIMA)

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time