Senior Inpatient Coder & DRG Specialist

Cape Fear Valley Health; Fayetteville (NC); On-site; USD 60,000 - 75,000; Full time

Job summary

Cape Fear Valley Health in Fayetteville, NC seeks a Health Information Management coder to thoroughly review medical records, code diagnoses, procedures, and comorbid conditions to support DRG assignment and reimbursement.

The role partners with Clinical Documentation Specialists and Reimbursement teams to ensure accurate documentation, engage with physicians about coding changes, and maintain a compliant, high-quality case mix index.

Qualifications

• Bachelor's degree in Health Information Management or 8 years of equivalent training and experience.
• RHIA, RHIT, CCS or other equivalent credentials are required.
• Minimum 5 years coding experience, hospital setting preferred.
• 2 years inpatient coding preferred.
• 1 year Health Information Management experience in an acute care facility or related setting preferred.

Responsibilities

• Code diagnoses, treatments, and procedures per UHDDS and coding guidelines.
• Abstract hospital admissions for reimbursement and statistics.
• Code LTAC, Rehab and acute care inpatients per payer requirements.
• Explain coding changes to physicians for attestation and possible PRO review.
• Assess documentation adequacy to support principal diagnosis and procedures.
• Collaborate with Clinical Documentation and Reimbursement specialists to improve physician documentation.
• Review OCE, NCCI, and CCI edits and apply appropriate modifiers.
• Identify opportunities to delay billing pending documentation to optimize DRG.
• Escalate issues to coding supervisor as needed.
• Perform other duties as assigned.

Skills

Medical coding

Healthcare terminology

UHDDS knowledge

Education

Bachelor's degree in Health Information Management or 8 years of equivalent training and experience

Tools

DRG grouper

Encoder software

Job description

Cape Fear Valley Health in Fayetteville, NC seeks a Health Information Management coder to thoroughly review medical records, code diagnoses, procedures, and comorbid conditions to support DRG assignment and reimbursement.

The role partners with Clinical Documentation Specialists and Reimbursement teams to ensure accurate documentation, engage with physicians about coding changes, and maintain a compliant, high-quality case mix index.