Senior Inpatient Coder: DRG & Documentation Expert

DHR Health; McAllen (TX); On-site; USD 65,000 - 90,000; Full time

Job summary

DHR Health seeks an Inpatient Coder to review and analyze documentation for inpatient visits, finalize codes, and ensure compliance with ICD-10-CM/PCS, CPT and HCPCS guidelines. The role emphasizes DRG validation and collaboration with CDS and medical staff to improve documentation quality.

Ideal candidates hold RHIA/RHIT/CCS/CIC with 3+ years hospital coding experience, strong medical knowledge, and proficiency in 3M coding software.

Qualifications

• RHIA, RHIT, CCS or CIC required; three to five years hospital experience.
• Extensive knowledge of medical terminology, anatomy and physiology, pharmacology and major diseases.
• Requires reasoning ability and independent judgment.
• Critical thinking skills, strong interpersonal skills and ability to multitask.
• 3M CRS software experience preferred.
• Understanding of HIPAA and health insurance laws/ethics.
• Capability to train and mentor junior staff; perform peer review and internal audits.

Responsibilities

• Promotes facility mission, vision and values.
• Accurately codes all inpatient diagnoses and procedures per ICD-10-CM/PCS, CPT and HCPCS guidelines.
• Adheres to AHIMA standards of ethical coding and coding compliance.
• References ICD-10-CM/PCS, CPT, and HCPCS Level II code books as needed.
• Attach HCPCS Level I and II modifiers when appropriate.
• Use 3M Coding references daily and 3M Coding Software for final coding.
• Maintain quality with 95% accuracy in chart coding.
• Communicate with Coding Manager to resolve issues and seek clarification.
• Attend relevant workshops and CE activities to stay current.

Skills

Medical terminology

Anatomy & physiology

Pharmacology

ICD-10-CM/PCS CPT HCPCS knowledge

Critical thinking

Communication

Multitasking

HIPAA/compliance

3M CRS software

Education

RHIA

RHIT

CCS

CIC

Tools

3M Coding Software

Job description

DHR Health seeks an Inpatient Coder to review and analyze documentation for inpatient visits, finalize codes, and ensure compliance with ICD-10-CM/PCS, CPT and HCPCS guidelines. The role emphasizes DRG validation and collaboration with CDS and medical staff to improve documentation quality.

Ideal candidates hold RHIA/RHIT/CCS/CIC with 3+ years hospital coding experience, strong medical knowledge, and proficiency in 3M coding software.