Hospital Inpatient Coder Certified - FT - Day - HIM Facility Coding Remote (NJ, PA, AL)

Capital Health System, Inc.; United States; Remote; USD 40,000 - 51,000; Full time

Benefits offered by this job

Medical Plan

Retirement Savings Plan

Paid Time Off

Job summary

Capital Health System, Inc. is seeking an experienced Health Information Coder to review inpatient records, assign ICD-10-CM and ICD-10-PCS codes, and determine correct DRGs.

The role collaborates with CDI and revenue cycle teams to ensure accurate reimbursement and compliance with guidelines. Qualified candidates will have CCS certification, hospital coding experience, and proficiency with encoder/EMR systems.

Qualifications

• High school diploma or equivalent required.
• CCS certification required.
• Previous hospital coding experience required.
• Knowledge of ICD-10-CM/ICD-10-PCS required.
• Experience with encoder and EMR systems required.

Responsibilities

• Review inpatient records and assign ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes.
• Assign accurate DRGs (MS-DRG/APR-DRG) and ensure proper reimbursement.
• Ensure MCC/CC, POA indicators, HACs, PSIs, SOI and ROM accuracy.
• Collaborate with CDI for complete documentation and optimal DRG assignment.
• Maintain coding credentials and stay current with ICD updates.

Skills

Communication skills

Attention to detail

Time management

Ability to work remotely

Education

Certified Coding Specialist (CCS)

RHIT

RHIA

High school diploma or equivalent

Tools

Encoder

EMR

Job description

Capital Health is the region's leader in providing progressive, quality patient care with significant investments in our exceptional physicians, nurses and staff, as well as advanced technology. Capital Health is a dynamic health care resource accredited by the DNV that includes two hospitals, an outpatient center, satellite ED, and an expansive network of primary and specialty care. Capital Health Medical Group is made up of more than 600 physicians and other providers who offer primary and specialty care, as well as hospital-based services, to patients throughout the region. Capital Health recognizes that attracting the best talent is key to our strategy and success as an organization.

As a result, we aim for flexibility in structuring competitive compensation offers to ensure we can attract the best candidates. The listed pay range or pay rate reflects compensation for a full-time equivalent (1.0 FTE) position. Actual compensation may differ depending on assigned hours and position status (e.g., part-time).

Pay Range: $28.70 - $37.32 Scheduled Weekly Hours: 40

Position Overview

Please note: While remote, we are only considering candidates in New Jersey, Pennsylvania, and Alabama Reviews and analyzes inpatient medical record documentation to assign accurate and compliant ICD-10-CM diagnosis codes, ICD-10-PCS procedure codes, and MS-DRG/APR-DRG groupings. Ensures proper reimbursement, supports quality reporting, and maintains compliance with official coding guidelines, payer regulations, and organizational policies. works independently while collaborating with clinicians, CDI, and revenue cycle teams as needed.

MINIMUM REQUIREMENTS

• Education: High school diploma or equivalent.
• Certified Coding Specialist (CCS) certification.
• Experience: Previous hospital coding experience.
• Other Credentials: CCS
• Knowledge and Skills: Possesses excellent organizational, interpersonal, verbal, and written communication skills.
• Has vigilance and keen attention to detail.
• Possesses proper phone and email etiquette for frequent hospital and private provider exchanges.
• Excellent time management to meet deadlines and productivity targets.
• Intermediate computer skills
• Special Training: Thorough knowledge of medical terminology, anatomy, and physiology.
• Understanding of ICD-10-CM, ICD-10-PCS.
• Knowledge and experience using an encoder, and EMR required.
• Mental, Behavioral and Emotional Abilities: Ability to work independently in a remote environment.
• Ability to work under pressure.
• Ability to work in a fast-paced environment with ability to meet quality and productivity standards.
• Ability to interact effectively with other staff members to complete certain aspects of job.
• Usual Work Day: 8 Hours
• Reporting Relationships Does this position formally supervise employees? No
• If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

ESSENTIAL FUNCTIONS

• Reviews complete inpatient medical records, including physician notes, operative reports, consultations, imaging, lab results, and discharge summaries.
• Assigns and properly sequences accurate ICD-10-CM diagnosis and ICD-10-PCS procedure codes in accordance with Official Coding Guidelines, UHDDS definitions, Coding Clinic guidance and CMS to a full range of inpatient services including cases with a high complexity level.
• Assigns correct and optimal DRGs (MS-DRG/APR-DRG).
• Ensures accurate capture of Major Comorbid Conditions (MCC)/Comorbid Conditions (CC), Present on Admission (POA) indicators, Hospital-Acquired Conditions (HACs), Patient Safety Indicators (PSIs), Severity of Illness (SOI) and Risk of Mortality (ROM).
• Issues compliant physician queries when documentation is incomplete, ambiguous, or inconsistent.
• Identifies documentation gaps and escape when clarification is needed.
• Resolves coding edits, queries, and discrepancies in a timely and compliant manner.
• Participates in internal and external audits; assist in implementing corrective action plans.
• Collaborates with Clinical Documentation Improvement (CDI) to ensure complete documentation and optimal DRG assignment.
• Supports coding leadership by identifying documentation improvement opportunities and workflow challenges.
• Meets or exceeds departmental accuracy and productivity standards.
• Codes inpatient encounters efficiently to support timely billing and reduce DNFB.
• Assists with reviewing accounts held for coding-related issues.
• Maintains required coding credentials (CCS, RHIT, RHIA).
• Stays current with all annual ICD-10-CM/PCS updates, DRG changes, and regulatory updates.
• Participates in continuing education, team meetings, and training sessions.
• Adapts to changing department demands required to maintain high level of performance.
• Performs other duties as assigned.

PHYSICAL DEMANDS AND WORK ENVIRONMENT

Frequent physical demands include: Occasional physical demands include: Standing , Walking , Push/Pull , Twisting , Bending , Reaching overhead , Talk or Hear Continuous physical demands include: Sitting , Reaching forward , Wrist position deviation , Pinching/fine motor activities , Keyboard use/repetitive motion Lifting Floor to Waist 15 lbs. Lifting Waist Level and Above 15 lbs. Sensory Requirements include: Accurate Near Vision, Accurate Far Vision, Accurate Depth Perception, Accurate Hearing Anticipated Occupational Exposure Risks Include the following: N/A IND123.

BENEFITS

• Medical Plan
• Prescription drug coverage & In-House Employee Pharmacy
• Dental Plan
• Vision Plan
• Flexible Spending Account (FSA) - Healthcare
• FSA - Dependent Care
• FSA
• Retirement Savings and Investment Plan
• Basic Group Term Life and Accidental Death & Dismemberment (AD&D) Insurance
• Supplemental Group Term Life & Accidental Death & Dismemberment Insurance
• Disability Benefits – Long Term Disability (LTD)
• Disability Benefits – Short Term Disability (STD)
• Employee Assistance Program
• Commuter Transit
• Commuter Parking
• Supplemental Life Insurance - Voluntary Life
• Spouse - Voluntary Life
• Employee - Voluntary Life
• Child Voluntary Legal Services
• Voluntary Accident, Critical Illness and Hospital Indemnity Insurance
• Voluntary Identity Theft Insurance
• Voluntary Pet Insurance
• Paid Time-Off Program

The pay range listed is a good faith determination of potential base compensation that may be offered to a successful applicant for this position at the time of this job advertisement and may be modified in the future. When determining base salary and/or rate, several factors may be considered including, but not limited to location, years of relevant experience, education, credentials, negotiated contracts, budget, market data, and internal equity. Bonus and/or incentive eligibility are determined by role and level. The salary applies specifically to the position being advertised and does not include potential bonuses, incentive compensation, differential pay or other forms of compensation, compensation allowance, or benefits health or welfare. Actual total compensation may vary based on factors such as experience, skills, qualifications, and other relevant criteria.

Equal Opportunity Employer Notice Capital Health Benefits