Inpatient Coder

Savista; Sacramento (CA); On-site; USD 60,000 - 80,000; Full time

Job summary

Savista is hiring a Coding professional to review clinical documentation and assign ICD-10 CM and PCS codes for Facility Inpatient records. The coder validates MS-DRG calculations to ensure accurate capture of diagnoses and procedures in our clinical data for billing and regulatory compliance.

The role involves abstracting clinical data, interacting with client staff, and maintaining privacy and data integrity in accordance with HIPAA. Ongoing education and credential maintenance are expected.

Qualifications

• Requires passing a pre-employment skills assessment.
• Credentials: AHIMA RHIA/RHIT/CCS or AAPC CPC/COC or related credentials.
• Two years of recent hands-on coding experience for Acute Inpatient.
• Knowledge of ICD-10 CM & PCS coding.
• Ability to maintain 95% accuracy/quality; meet production standards.
• Proficient with MS Office; basic data entry, email, calendar tasks.

Responsibilities

• Select and sequence ICD-10 CM and PCS codes for designated patient types (Acute Facility Inpatient).
• Review and analyze clinical records to ensure MS-DRG assignments reflect diagnoses/procedures.
• Abstract clinical data to support diagnoses, procedures and discharge disposition.
• Complete assigned work using available resources.
• Serve as a resource for data integrity and compliant coding practices.
• Maintain patient/provider confidentiality per HIPAA; participate in meetings and training.
• Stay current on ICD-10 CM/PCS, coding guidelines, regulations, and third-party requirements; pursue continuing education.

Skills

Medical coding

ICD-10-CM

ICD-10-PCS

HIPAA compliance

MS Office

Analytical skills

Communication

Education

AHIMA RHIA/RHIT/CCS or AAPC CPC/COC credential

Tools

MS Office

EMR systems

Job description

JOB SUMMARY

The Coder will review clinical documentation to assign and sequence diagnostic and procedural codes for Facility Inpatient records to meet the needs of hospital data retrieval for billing and reimbursement. Coder validates MS-DRG calculations to accurately capture the diagnoses and procedures documented in the clinical record. Coder performs documentation review and assessment for accurate abstracting of clinical data to meet regulatory compliance requirements. Coder may interact with client staff and providers.

JOB ACCOUNTABILITIES

• Select and sequence ICD-10 CM and PCS codes for designated patient types which may include but is not limited to: Acute Facility Inpatient for Non-Teaching Level facilities.
• Review and analyze clinical records to ensure that MS-DRG assignments accurately reflect the diagnoses/procedures documented in the clinical record.
• Abstract clinical data from the record after documentation review to ensure that it is adequate and appropriate to support diagnoses, procedures and discharge disposition is selected.
• Complete assigned work functions utilizing appropriate resources.
• May act as a resource with client staff for data integrity, clarification and assistance in understanding and determining appropriate and compliant coding practices including provider queries.
• Maintain strict patient and provider confidentiality in compliance with HIPPA.
• Participate in client and staff meetings, trainings, and conference calls as requested and/or required.
• Maintain current working knowledge of ICD-10 CM and PCS and coding guidelines, government regulations, protocols, and third-party requirements regarding coding and/or billing.
• Participate in continuing education activities to enhance knowledge, skills, and maintain current credentials.
• Support Savista's Compliance Program by demonstrating adherence to all relevant compliance policies and procedures as evidenced by in-service attendance and daily practice; notifying management when there is a compliance concern or incident; demonstrating knowledge of HIPAA Privacy and Security Regulations as evidenced by appropriate handling of patient information; promoting confidentiality and using discretion when handling patient and/or client information.
• Performs other related duties as assigned or requested.

QUALIFICATIONS

• Candidates must successfully pass pre-employment skills assessment.
• An active AHIMA (American Health Information Association) credential including but not limited to RHIA, RHIT, CCS or an active AAPC (American Academy of Professional Coders) credentials COC (formerly CPC-H), CCS-P, or CPC or related specialty credential.
• Two (2) years of recent and relevant hands-on coding experience with all record types: Acute Inpatient.
• Knowledge of medical terminology, anatomy and physiology, pharmacology, pathophysiology, as well as ICD-10 CM & PCS code sets.
• Ability to consistently code at 95% threshold for both accuracy and quality while maintaining client-specific and/or Savista production and/or quality standards.
• Proficient computer knowledge including basic MS Office knowledge. Basic MS Office knowledge includes data entry, sort, filter, copy, paste and password protect functions in Excel and/or Word programs. Basic MS Outlook knowledge is opening and responding to emails and accepting and scheduling meetings using the Outlook calendar.
• Must display excellent interpersonal and problem-solving skills with all levels of internal and external customers.

SAVISTA is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, age, veteran status, disability, national origin, sex, sexual orientation, religion, gender identity or any other federal, state or local protected class.