Inpatient Coder II

101 Riverside Hospital, Inc.; United States; Remote; USD 57,000 - 78,000; Full time

Job summary

101 Riverside Hospital, Inc. in Newport News, Virginia is seeking an Inpatient Coder II to analyze medical records, assign ICD-10-CM/PCS codes, and ensure accurate DRG assignments.

You will abstract information, verify POA indicators, and collaborate with the CDI team to meet four-day turnaround times and monthly goals. Certifications include CCS, CCA, RHIA, RHIT, CIC.

Qualifications

• Active inpatient coding experience (acute care) 3–4 years required.
• Certified inpatient coder credentials required.

Responsibilities

• Assign ICD-10-CM/ICD-10-PCS codes to determine DRG assignments.
• Abstract pertinent information from patient records and sequence diagnoses.
• Verify POA indicators and discharge disposition on inpatient accounts.
• Query physicians when documentation is unclear or incomplete for coding.
• Maintain four-day turnaround times and meet productivity targets.
• Collaborate with CDI and other departments to meet goals.

Skills

ICD-10-CM coding

DRG assignment

Medical terminology

POA indicators

Communication

Education

High School Diploma or GED

HIMS program graduate or related

Tools

3M Encoder

EPIC EMR

Microsoft Office

Job description

Newport News, Virginia Hiring Range $27.30 - $37.58/Hourly Actual pay is determined based on job-related factors such as relevant experience, education, credentials, skills, internal equity, and business needs. This position is remote work eligible for candidates residing in the following states: FL, GA, ID, KS, KY, MS, NC, OK, SC, SD, TN, VA.

Overview: The Inpatient Coder II is responsible for analyzing the medical record to assign International Classification of Diseases (ICD) Clinical Modification (CM) diagnoses and Procedure Coding System (PCS) procedure codes to ensure correct code assignment and optimal reimbursement in compliance with state and federal guidelines. Works in collaboration with the Clinical Documentation Improvement (CDI) team to ensure accurate Diagnosis Related Group (DRG) assignment and works closely with management to resolve problems and meet deadlines.

What you will do

• Assigns International Classification of Diseases (ICD)-10-CM Clinical Modification (CM) and ICD-10-Procedure Coding System (PCS) codes creating diagnosis-related group (DRG) assignments.
• Abstracts pertinent information from patient records.
• Sequences the diagnosis and procedures using coding guidelines and optimizing the diagnosis-related group (DRG) as applicable.
• Apply present on admission (POA) indicators and verify the discharge disposition is correct on all inpatient accounts.
• Communicates with Clinical Documentation Improvement (CDI) on mismatches to include diagnosis-related group (DRG), principal diagnosis selection, complication or comorbidities (CC), major complication or comorbidities (MCC), hospital acquired conditions (HAC), patient safety indicators (PSI), and severity of illness and risk of mortality (SOI/ROM) on reviewed cases.
• Identifies the need for clinical validation and works with the Clinical Documentation Improvement (CDI) department to review documentation and/or request provider documentation clarification.
• Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous or unclear for coding purposes.
• Maintains four-day turnaround times for inpatient coding based on the discharge date and total charges, while meeting productivity standards.
• Collaborates with other departments to meet departmental monthly goals which include one or more of the following: DNFB (discharged not final billed), Denials, and Claim Edits.
• Participates in ongoing coding educational webinars routinely and as needed.
• Reviews individually audited cases by third party companies and/or internal audits and provides a rebuttal if needed.
• Participates in the development of coding policies and procedures.

Qualifications

• Education High School Diploma or GED, (Required) Program Graduate, Health Information Management Services (HIMS) or related (Preferred)
• Experience 3-4 years Active Inpatient Coding (Acute Care) (Required)
• Skills and Abilities Demonstrates support and compliance with Riverside Health Systems mission, vision, values statement, goals and objectives and policies. Must have extensive knowledge of medical terminology, the human disease process, clinical science, anatomy and physiology, pathophysiology and laboratory medicine. Must be able to communicate clearly and concisely verbally and in writing to ensure that the intended audience understands the information and the message. Ability to listen and respond appropriately to others. Must be able to present information in an organized and professional manner. Knowledgeable in Microsoft Office, use of encoder (3M 360 preferred) and use of an electronic medical record (EMR) (EPIC preferred).

Licenses and Certifications

• Certified Coding Specialist (CCS) - The American Health Information Management Association (AHIMA) (Required)
• Certified Coding Associate (CCA) - The American Health Information Management Association (AHIMA) (Required)
• Registered Health Information Administrator (RHIA) - The American Health Information Management Association (AHIMA) (Required)
• Registered Health Information Administrator (RHIT) - The American Health Information Management Association (AHIMA) (Required)
• Certified Inpatient Coder (CIC) - American Academy of Professional Coders (AAPC) (Required)

By joining our team, you can make a difference in people's lives. Our mission is to care for others as we would care for those we love. We extend that sense of caring to every patient, resident and customer, as well as to each member of our team. We offer care at all stages of life, in hundreds of locations, giving you room to grow your career, along with great benefits and perks. At Riverside Health, your trust and safety are our top priorities.