Medical Coder - Inpatient

St. Joseph's/Candler; Roswell (GA); On-site; USD 65,000 - 82,000; Full time

Job summary

St. Joseph's/Candler is seeking an Inpatient Coder to finalize coding for acute care, mother/baby, inpatient rehab and skilled nursing. You will assign ICD-10-CM and ICD-10-PCS codes, group DRGs, and validate POA indicators. Remote CDI collaboration may be required to ensure accurate data capture.

The role emphasizes adherence to AHIMA/AAPC guidelines, ongoing education, and quality/compliance in a HIPAA-compliant environment.

Qualifications

• 2-3 years of medical coding experience in inpatient settings.
• Experience with ICD-10-CM/ICD-10-PCS and DRG grouping.
• Knowledge of POA indicators and coding guidelines.

Responsibilities

• Review medical records and assign diagnosis and procedure codes accurately.
• Sequence codes to group to correct DRG and validate POA indicators.
• Submit physician queries post-discharge to clarify documentation.
• Ensure compliance with ICD-10-CM/PCS guidelines and CPT coding rules.
• Collaborate with CDI team and stay current with coding changes.

Skills

Medical coding

Inpatient coding

DRG understanding

Education

Associates of Health Information Administration

Tools

Medical coding software

Job description

Position Summary

This position is responsible for final coding of inpatient accounts including acute care, mother/baby, inpatient rehab and skilled nursing. Inpatient coders follow coding conventions and guidelines to abstract, analyze and accurately assign ICD-10-CM diagnosis codes and ICD-10-PCS procedure CPT and HCPCS codes. Inpatient coders are required to utilize the computer assisted coding features of the encoder to accurately group DRGs and to validate diagnoses that group to an APR-DRG.

Assigns present on admission indicator codes in compliance with national quality measures. Abstracts and validates other data elements as required.

Education

• Associates of Health Information Administration


• Preferred

Experience

• 2-3 Years Medical coding


• Required


• 1-2 Years Inpatient coding


• Preferred

License & Certification

• National Certification


• Required


• American Health Information Management Association: RHIA, RHIT, CCS

Core Job Functions

• Accurately reviews medical records and assigns diagnosis and procedure codes utilizing the computerized encoding software system; sequences codes to group to the correct DRG; assigns an appropriate POA indicator to codes. Submits post discharge physician queries to clarify ambiguous or conflicting documentation. Validates admission and discharge data; abstracts other required data.


• Follows the standards of professionalism set forth by AHIMA and AAPC. Ethically and accurately assigns diagnosis and procedure codes in compliance with the ICD-10-CM/PCS Official Coding Guidelines, Coding Clinic, and CPT procedure codes in accordance with the CPT guidelines and CPT Assistant guidance.


• Exhibits strong teamwork skills to identify and clarify clinical and coding issues. Collaborates with CDI team to ensure all relevant diagnoses are captured for quality measures. Offers coding education as needed and requests clinical education.


• Maintains certification and engages in continuing education activities. Stays up-to-date on coding changes, Coding Clinic advice, and payor regulations including national and local policies. Shares knowledge with the rest of the team.


• Able to work independently and maintain quality and productivity standards in a remote, HIPAA compliant home environment to ensure goals are met. Identifies and escalates any obstacles to fulfilling job responsibilities. Takes initiative to resolve technical issues and maintains strong communication with coding management.