Inpatient Coding Apprentice

Singing River Health System; United States; On-site; USD 36,000 - 48,000; Full time

Job summary

Singing River Health System is seeking an Inpatient Coding Apprentice to evaluate medical records and ensure compliance with ICD-10-CM, HCPCS, CMS, and CPT guidelines. The role involves abstracting information, identifying DRG assignments, and guiding physicians on coding expectations.

Responsibilities include reviewing complex charts, reporting documentation issues, and training staff on coding practices, while maintaining HIPAA confidentiality.

Qualifications

• High School diploma or equivalent required.
• Must have de-escalation training completed by the end of position orientation (90 days).
• Experience in medical terminology and anatomy/physiology preferred.

Responsibilities

• Evaluate medical records to ensure completeness, accuracy and compliance with ICD-10-CM, HCPCS, CMS, CPT guidelines.
• Review complex medical records to identify diagnoses, CPT procedures and PCS procedures.
• Select principal diagnosis and principal procedure, along with other diagnoses and procedures using UHDDS definition.
• Ensure appropriate DRG assignment and abstract relevant information from records.
• Identify and report documentation issues and solicit physician clarification for ambiguity.
• Provide technical guidance and training on medical coding to physicians and staff.

Skills

Medical terminology

Anatomy & physiology

Verbal communication

Written communication

Attention to detail

Education

High School diploma or equivalent

Tools

MS Outlook

MS Word

Keyboard proficiency

Job description

At Singing River Health System, caring isn’t just part of the job — it’s in our DNA. Whether we’re saving lives, supporting behind the scenes, or showing up for our community, we bring the energy, heart, and hustle every single day. With pride, passion, and commitment, we will improve health and save lives in our community every day. Shift: Monday - Friday (7:00 AM - 3:30 PM) Location: Singing River Healthcare Academy

Job Description Summary

Job Description Position Overview: The Inpatient Coding Apprentice will evaluate medical records and documentation to ensure completeness, accuracy, and compliance with the International Classification of Diseases Manual - Clinical Modification (ICD-10-CM), Healthcare Common Procedure Coding System (HCPCS), Centers for Medicare and Medicaid Services (CMS) documentation requirements and the American Medical Association’s Current Procedural Terminology Manual (CPT). Reviews complex medical records to identify diagnoses, CPT procedures and PCS procedures relative to the patient’s encounter. Selects the principal diagnosis and principal procedure, along with other diagnoses and procedures using UHDDS definition. Ensures appropriate DRG assignment. Abstracts appropriate information from the complex medical record. Identifies and reports documentation issues. Solicits clarification from the physician regarding ambiguous or conflicting documentation in the medical record. Ensure all coding complies with the ethical coding standards/guidelines and regulatory requirements. Maintains strictest confidentiality; adheres to all Health Insurance Portability and Accountability Act guidelines/regulations. The Specialist will also provide technical guidance and training on medical coding to physicians and staff.

DISCLAIMER: This is not necessarily an exhaustive list of all responsibilities, duties, skills, efforts, requirements or working conditions associated with the job. While this intends to be an accurate reflection of the current job, management reserves the right to revise the job or to require that other or different tasks performed as assigned.

Education

High School diploma or equivalent required.

License

N/A

Certifications

Must have de-escalation training completed by the end of position orientation (90 days); must have appropriate level of de-escalation training.

Experience

Experience in medical terminology and anatomy/physiology preferred.

Reports to

Educator-Inpatient Coding Apprentice

Supervises

None

Physical Demands

Work is mainly sedentary: involves sitting most of the time with regular requirements to move about the office, move about the facility, and to travel to another facility within the SRHS service area. Work involves exerting a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Work involves using many physical motions in performing daily work activities; subject to exposure of body fluids, sputum and tissues, which may carry the hazard of infectious disease. Work involves using repetitive motions: substantial movements of the wrists, hands, and or fingers while operating standard office equipment such as computer keyboard. Work involves being able to perceive the nature of sound at normal speaking levels with or without correction; the ability to make fine discriminations in sound. Work requires close visual and acuity and the ability to adjust the eye to bring an object into sharp focus, i.e. shift gaze from viewing a computer monitor to forms/printed material that are closer to compare data at close vision. Must be able to be active for extended periods of time without experiencing undue fatigue. Must be able to work schedules assigned with the understanding that changes may be instituted according to the needs of the hospital for off days, shifts or weekends.

Mental Demands

Must demonstrate keen mental faculties/assessment and decision making abilities. Must demonstrate superior communication/speaking/enunciation skills to receive and give information in person and by telephone. Must demonstrate strong written and verbal communication skills. Must possess emotional stability conducive to dealing with high stress levels. Must demonstrate ability to work under pressure and meet deadlines. Attention to detail and the ability to multi-task in complex situations is required. Must have the ability to maintain collaborative and respectable working relationships throughout SRHS and other organizations.

Special Demands

Must possess superior customer service skills and professional etiquette. Must possess proficient knowledge and ability to use a computer (must be keyboard proficient) and other office technology (i.e., telephone, fax, etc.), MS Outlook and Word. Job requires traveling throughout the SRHS service area – with the employee providing his/her own transportation. Must have knowledge of anatomy, physiology and medical terminology; and have knowledge of DRGs/APC’s. Must successfully pass the Medical Records Coding tests (CPT and ICD-10) with a score of at least 70%.

If you’re looking for purpose, teamwork, and a place where what you do truly matters, you’ve found it. Let’s do big things together.

Singing River is both a mission-driven healthcare provider and one of the largest employers on the Mississippi Gulf Coast. We offer best-of-industry benefits, scheduling options, and professional pathways for our employees. Within each of our three hospitals and 50+ primary care and specialty clinics, you'll find a team devoted to quality, teamwork, and service.