Senior Inpatient Medical Coder (DRG Specialist)

Cape-Fear-Valley-Medical-Center-; Fayetteville (NC); On-site; USD 70,000 - 95,000; Full time

Job summary

Cape Fear Valley Medical Center in Fayetteville, NC seeks a Health Information Management professional to code diagnoses, procedures, and treatments for hospital encounters. You will abstract admissions for reimbursement and ensure documentation supports principal diagnoses and comorbidities.

The role requires hospital coding experience with RHIA/RHIT/CCS credentials and strong communication with physicians to optimize DRG outcomes.

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 in a hospital setting; 2 years inpatient coding preferred.
• In-depth knowledge of UHDDS, ICD-CM coding principles, and payer rules.

Responsibilities

• Code diagnoses, treatments, and procedures using appropriate coding systems.
• Abstract hospital admissions for reimbursement and statistical reporting.
• Code LTAC, Rehab and acute care inpatients per payer requirements with encoder/DRG grouper.
• Explain principal diagnosis changes to physicians when documentation affects attestation.
• Assess documentation adequacy to support principal diagnoses, procedures, and comorbidities.
• Collaborate with Clinical Documentation Specialists and Reimbursement Specialists to improve physician documentation.
• Analyze clinical findings to determine secondary diagnoses for severity indices and appropriate DRG.
• Delay billing when additional documentation is needed for optimal DRG assignment.

Skills

UHDDS knowledge

ICD-CM coding

Physician communication

Medical terminology

Analytical reasoning

Education

Bachelor's degree in Health Information Management

RHIA/RHIT/CCS or equivalent credentials

5 years hospital coding experience

2 years inpatient coding preferred

1 year HIM experience in acute care

Tools

Encoder software

DRG grouper

Job description

Cape Fear Valley Medical Center in Fayetteville, NC seeks a Health Information Management professional to code diagnoses, procedures, and treatments for hospital encounters. You will abstract admissions for reimbursement and ensure documentation supports principal diagnoses and comorbidities.

The role requires hospital coding experience with RHIA/RHIT/CCS credentials and strong communication with physicians to optimize DRG outcomes.