Senior Inpatient Clinical Coder - DRG & Reimbursement

Cape Fear Valley Health; Fayetteville, Northern (NC, KY); Hybrid; USD 65,000 - 90,000; Full time

Job summary

Cape Fear Valley Health in Fayetteville, NC, seeks a Health Information Management professional to code diagnoses, procedures and charges for hospital encounters. You will ensure UHDDS compliance and accurate DRG assignment.

Responsibilities include medical record abstraction, physician attestation communication, and collaboration with reimbursement teams to improve documentation and claim accuracy.

Qualifications

• Bachelor's degree in Health Information Management or equivalent 8 years experience.
• 5 years coding experience; 2 years inpatient preferred.
• RHIA/RHIT/CCS or equivalent credentials required.
• Proficiency in reading, writing, and speaking English.
• Knowledge of UHDDS definitions and ICD-CM coding principles.
• Excellent communication skills.
• Ability to work in a busy hospital env with focus on accuracy.

Responsibilities

• Code diagnoses, treatments and procedures per UHDDS guidelines and payer rules.
• Perform medical record abstracting for reimbursement and statistics.
• Concurrently code LTAC, Rehab and acute care inpatients per payer requirements.
• Explain principal diagnoses changes to physicians for attestation statements.
• Assess documentation to support principal diagnosis, procedures and comorbidities.
• Collaborate with CDI and Reimbursement Specialists to improve documentation.
• Assess OCE, NCCI and CCI edits to apply modifiers and refer for billing.
• Analyze findings to determine secondary diagnoses for severity indices.
• Know when to delay billing for additional documentation.
• Notify coding supervisor of issues affecting performance.
• Other duties as assigned.

Skills

English proficiency

Communication skills

ICD-CM coding

UHDDS knowledge

Education

Bachelor's degree in Health Information Management

RHIA/RHIT/CCS credentials

Tools

Computer encoder

DRG grouper

Job description

Cape Fear Valley Health in Fayetteville, NC, seeks a Health Information Management professional to code diagnoses, procedures and charges for hospital encounters. You will ensure UHDDS compliance and accurate DRG assignment.

Responsibilities include medical record abstraction, physician attestation communication, and collaboration with reimbursement teams to improve documentation and claim accuracy.