Inpatient Coder

Houston Methodist; Miami (FL); On-site; USD 65,000 - 85,000; Full time

Job summary

Houston Methodist is seeking an Inpatient Coder to assign diagnostic and procedural codes for inpatient encounters based on documentation within the electronic medical record, ensuring accuracy and compliance with established coding guidelines.

Responsibilities include querying physicians when needed, maintaining high-quality data in EPIC/EHR, and meeting productivity standards while supporting coding education and collaboration with the coding team.

Qualifications

• One year of inpatient coding experience or completion of the Houston Methodist Coding Apprentice Program or equivalent transition program.
• Associate's degree or higher in a CAHIIM accredited program or equivalent experience as substitute for degree.

Responsibilities

• Assign ICD-10-CM/ICD-10-PCS codes for inpatient encounters based on documentation in the EMR.
• Query physicians to obtain or clarify diagnoses or procedures as appropriate.
• Maintain coding quality and productivity within hospital policy and regulatory guidelines.
• Review medical record documentation and abstract data into encoder and EPIC/EHR to determine principal diagnosis and procedures.

Education

CAHIIM accredited program or equivalent experience

Tools

Electronic encoder application

EPIC/EHR

Job description

At Houston Methodist, the Inpatient Coder position is responsible for ensuring diagnostic and procedure codes are assigned accurately to inpatient encounters based upon documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines.

FLSA STATUS

Non-exempt

QUALIFICATIONS

EDUCATION

• Associate's degree or higher in a CAHIIM accredited program or additional two years of experience (in addition to the minimum experience requirements listed below) in lieu of degree

EXPERIENCE

• One year of relevant inpatient coding experience or successful completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program

LICENSES AND CERTIFICATIONS

Required

• Must have one of the following: - RHIT - Certified Health Information Technician (AHIMA) - RHIA - Registered Health Information Administrator (AHIMA) - CCS - Certified Coding Specialist (AHIMA)

SKILLS AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles

• Knowledge of coding classification systems, DRG and APC systems, official coding guidelines and coding compliance

• Knowledge of an electronic medical record and imaging systems preferred

• Working knowledge of medical terminology, anatomy and physiology

• Proficiency with electronic encoder application preferred

• Extensive PC knowledge - must be able to work effectively in common office software, coding software and abstracting systems

ESSENTIAL FUNCTIONS

PEOPLE ESSENTIAL FUNCTIONS

• Interacts and communicates effectively with members of the coding team and the appropriate stakeholders.

• Participates and provides good feedback during coding section meetings and coding education inservices as well as takes initiative to assist others and shares knowledge with the appropriate stakeholders.

SERVICE ESSENTIAL FUNCTIONS

• Responds promptly to internal and external customer requests. Responds promptly and appropriately to requests to code or review coded accounts for accuracy.

• Initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Maintains and achieves the highest standards of coding quality by assigning accurate/ICD-10-CM/ICD-10-PCS codes utilizing an electronic encoder application in accordance with hospital policy and regulatory body guidelines.

• Maintains and achieves department standards of abstracting quality by reviewing accurate discharge disposition entered by nursing and corrects if necessary in order to achieve the highest quality of entered data. Assigns and enters physician identification number and procedure date correctly in the medical record abstracting system.

• Reviews medical record documentation and abstracts data into the encoder and EPIC/Electronic Health Record (EHR) to determine principal or final diagnosis, co-morbid conditions and complications, secondary conditions and procedures. Utilizes all tools/ resources for accuracy.

• Complies with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official guidelines.

FINANCE ESSENTIAL FUNCTIONS

• Utilizes time effectively. Consistently codes and abstracts at departmental standards of productivity while ensuring accuracy of coding.

• Supports meeting organizational goal for Accounts Receivables (AR) associated with uncoded accounts.

• Maintains coding timeframes within established departmental standards by ensuring all work items assigned to the coding queues are processed in a timely manner.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Critically evaluates her or his own performance, accepts constructive criticism, and looks for ways to improve.

• Displays initiative to improve relative to job function. Contributes ideas to help improve quality of coding data and abstracting data.

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform: No

• Scrubs: No

• Business professional: Yes

• Other (department approved): No

ON-CALL*

*Note that employees may be required to be on-call during emergencies (ie. Disaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**

Travel specifications may vary by department

• May require travel within the Houston Metropolitan area Yes

• May require travel outside Houston Metropolitan area Yes

QUALIFICATIONS

EDUCATION

• Associate's degree or higher in a CAHIIM accredited program or additional two years of experience (in addition to the minimum experience requirements listed below) in lieu of degree

EXPERIENCE

• One year of relevant inpatient coding experience or successful completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program

LICENSES AND CERTIFICATIONS

Required

• Must have one of the following:- RHIT - Certified Health Information Technician (AHIMA)- RHIA - Registered Health Information Administrator (AHIMA)- CCS - Certified Coding Specialist (AHIMA)

Company Profile:

Houston Methodist is one of the nation's leading health systems and academic medical centers. The health system consists of eight hospitals: Houston Methodist Hospital, its flagship academic hospital in the Texas Medical Center, seven community hospitals and one long-term acute care hospital throughout the Greater Houston metropolitan area. Houston Methodist also includes a research institute; a comprehensive residency program; international patient services; freestanding comprehensive care clinics, emergency care and imaging centers; and outpatient facilities. Come lead with us!

Houston Methodist is an Equal Opportunity Employer.