Inpatient Coding Specialist II - APR-DRG (CCS Required)

MedStar Health; United States; In loco; USD 40.000 - 67.000; Tempo pieno

Descrizione del lavoro

MedStar Health is seeking an Inpatient Coding Specialist II to analyze clinical documentation and assign accurate inpatient codes using ICD-10-CM/PCS. The role requires evaluating diagnoses and procedures, querying physicians when needed, and maintaining compliance with regulatory standards.

The position emphasizes continuing education, credential maintenance, and participation in quality and service improvement teams, with a focus on accurate DRG determinations across MedStar facilities.

Competenze

• High School Diploma or GED required.
• Associate's or Bachelor's degree in coding related field preferred.
• Courses in Medical Terminology, Anatomy & Physiology ICD-10-CM/PCS required.

Mansioni

• Analyze and interpret clinical documentation to assign correct inpatient codes.
• Abstract diagnoses, procedures, demographics and other data elements for accuracy.
• Query physicians when information is conflicting or ambiguous.
• Maintain compliance with regulations and ongoing education.
• Ensure accuracy and timely completion of quality reviews and DRG assignments.
• Participate in meetings and multi-disciplinary quality improvement initiatives.

Conoscenze

Verbal and written communication

Basic computer skills

Analytical skills

Organizational skills

Formazione

High School Diploma or GED

Associate's degree in coding related field

Bachelor's degree in coding related field

Courses in Medical Terminology, Anatomy & Physiology, ICD-10-CM/PCS

Strumenti

Solventum System

Electronic medical records

Coding software

Descrizione del lavoro

About the Job

General Summary of Position

The Inpatient Coding Specialist II analyzes and interprets clinical documentation to accurately code and abstract inpatient facility records for all MedStar entities in accordance with established ICD-10-CM/PC​S coding classification systems.

Primary Duties and Responsibilities

• Contributes to the achievement of established department goals and objectives and adheres to department policies procedures quality standards and safety standards. Complies with governmental and accreditation regulations.
• Abstracts and ensures accuracy of diagnoses procedure patient demographics and other required data elements.
• Adheres to all compliance regulations and maintains annual compliance education.
• Maintains continuing education and seeks ongoing education to improve job performance. Maintains credentials as required for job classification.
• Contacts physician when conflicting or ambiguous information appears in the medical record. Adheres to the MedStar Coding Query Policy and procedure.
• Consistently meets or exceeds established Quality standards as defined by policies.
• Consistently meets or exceeds established Productivity standards as defined by policies.
• Resolves all quality reviews timely (e.g. Medical necessity reviews; Coding Quality assurance reviews; external vendor reviews).
• Reviews medical record documentation to identify diagnoses and procedures. Assigns correct diagnostic and procedural codes using standard guidelines and automated encoding software maintaining departmental accuracy standards. Determines the sequence of diagnoses according to Uniform Hospital Discharge Data Definitions and assigns appropriate DRG (Diagnosis Related Groups).
• Exhibits knowledge of the Solventum system and other work-related equipment.
• Participates in meetings and on committees and represents the department and hospital in community outreach efforts.
• Participates in multi-disciplinary quality and service improvement teams.
• Performs other duties as assigned.

Minimal Qualifications

Education

• High School Diploma or GED required
• Associate's degree in coding related degree preferred or
• Bachelor's degree in coding related degree preferred and
• Courses in Medical Terminology Anatomy & Physiology ICD-CM and ICD-PCS required

Experience

• 3-4 years Inpatient coding experience required
• Experience with clinical information systems (Solventum grouper electronic medical records computer assisted coding) required

Licenses and Certifications

• CCS (Certified Coding Specialist) required and
• RHIT (Registered Health Information Technician) preferred and
• RHIA (Registered Health Information Administrator) preferred and

Knowledge Skills and Abilities

• Verbal and written communication skills.
• Basic computer skills required.
• Strong analytical and organizational skills; ability to prioritize workloads and meet deadlines.

This position has a hiring range of

USD $28.76 - USD $48.96 /Hr.