Inpatient Coder III - Per Diem: Remote

TuftsMedicine; United States; Remote; USD 70,000 - 90,000; Full time

Job summary

TuftsMedicine is seeking a certified inpatient coder to review medical records and assign ICD-10-CM and ICD-10-PCS codes for inpatient admissions. The role emphasizes accurate coding, collaboration with providers, and participation in audits to ensure proper reimbursement.

The position is fully remote within the United States, with flexible start times and weekend coverage strongly preferred. Training and orientation are provided on start date, with EST hours for training.

Qualifications

• High school diploma or equivalent.
• CCS, CIC, RHIA or RHIT certification.
• Three years of ICD-10-CM and PCS coding experience.
• EMR experience.

Responsibilities

• Verifies and abstracts clinical data from patient records.
• Assigns accurate ICD-10-CM and ICD-10-PCS codes from documentation.
• Reviews reports with leadership to identify discrepancies.
• Queries providers to obtain missing documentation when needed.
• Ensures timely submission of coded data (within 72 hours of discharge).
• Collaborates with Compliance, Educators, and Auditors on coding quality.

Skills

ICD-10-CM/PCS coding

EMR experience

Data accuracy

Education

CCS Certification

RHIA/RHIT or CIC certification

Tools

Epic

CAC

Job description

Hours: Up to 30 hours per week. Assistance needed for month end, vacation coverage, etc. Flexibility with start/end time. Weekend coverage strongly preferred.

Location: 100% remote.

Requirements: Virtual orientation held on your start date (Monday, 8:30-5). Ability to conduct training during the hours of 6 AM to 6 PM (EST) M-F.

Job Overview

This position reviews medical records to assure accurate specificity of diagnoses and procedures for inpatient admissions. Effectively utilizes ICD-10 CM and PCS codes according to coding guidelines. Communicates effectively with providers and/or all appropriate staff regarding missing information such as diagnosis, procedure, and documentation issues, to ensure proper coding and reimbursement. Manages the creation of deficiencies, within Epic, for missing documentation. Works with leadership to review denial reports as well as participating in internal and external audits to ensure documentation, code capture, and billing are accurate and precise. Informs supervisor of unusual/problematic accounts, issues, concerns, and opportunities for improvement. Attends meetings and education sessions as requested with participation. Performs any other related duties as assigned.

Job Description

Minimum Qualifications:

• 1. High school diploma or equivalent.
• 2. Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT).
• 3. Three (3) years of ICD-10-CM and PCS coding experience
• 4. EMR experience

Preferred Qualifications:

• 1. Associates degree.
• 2. Five (5) years of Inpatient ICD-10-CM and PCS coding experience within a Teaching hospital or Level One Trauma Center.
• 3. Epic and CAC Experience

Duties and Responsibilities:

• 1. Verifies and abstracts clinical and demographic data from the patient record.
• 2. Performs chart audits prior to coding to ensure required documentation is complete and signed. Queries appropriate providers or departments when deficiencies prevent the start of the coding process.
• 3. Assigns accurately ICD-10 CM an ICD10 PCS codes, derived from medical record documentation for patient account.
• 4. Reviews reports with leadership to identify discrepancies.
• 5. Reviews audit lists regarding coding/billing changes, as well as denial reports.
• 6. Identifies and evaluates coding issues, summarizes findings for leadership, makes recommendations for course of action. Works actively with physicians to initiate corrections and resolve discrepancies in coding and documentation.
• 9. Ensures that all accounts are submitted accurately and in a timely manner.
• 10. Works collaboratively with Compliance, Educators, and Auditors
• 11. Ensures that all medical records are coded and abstracted within 72 hours of patient discharge.
• 12. Responsible to follow-up on assigned discharges for final coding.
• 13. Acts as a resource for answering coding questions from interdepartmental staff.
• 14. Documents results of all special project work and providing recommendations relating to special projects.
• 15. Attend meetings as necessary and participates on projects to ensure that all services are captured through codes.
• 16. Maintains good relationship with providers and office personnel to facilitate good communication in coding queries.
• 17. Promote excellent customer service. Identify and communicate problems and/or opportunities to improve processes with management.
• 18. Maintains collaborative, team relationships with peers and colleagues in order to effectively contribute to the working groups achievement of goals, and to help foster a positive work environment
• 19. Performs job junctions adhering to service principles with customer service focus of innovation, service excellence and teamwork to provide the highest quality care and service to our patients, families, colleagues and community.
• 20. Participates in coding audits coding staff in order to maintain quality standards and offer feedback to management
• 21. Works closely with the DRG Validator to maintain high coding standards.

Physical Requirements:

• 1. Sedentary role which requires sitting most of the time, occasional standing & walking. Mental requirements will be intense at times with involvement in many concurrent multi-faceted projects.
• 2. Manual dexterity using fine hand manipulation to operate computer keyboard.
• 3. Ability to see computer screen and reports.

Skills & Abilities:

• 1. Excellent organizational skills and able to balance working on multiple tasks and provide timely follow through.
• 2. Effective interpersonal and communication skills.
• 3. Ability to work under pressure and meet deadlines.
• 4. Ability to communicate verbally, by phone or virtually, with colleagues and medical staff.
• 5. Knowledge of Excel and basic computer skills.
• 6