Job Description

We are seeking a detail-oriented and experienced In-Patient Medical Coder to support accurate and compliant coding of inpatient medical records. The role involves reviewing clinical documentation and assigning appropriate diagnosis and procedure codes to ensure timely and accurate billing processes. The ideal candidate has a strong command of inpatient coding standards and is comfortable working with diverse clinical documentation from multiple sources.

Key Responsibilities:

• Review and analyze inpatient medical records to assign accurate ICD-10-CM, ICD-10-PCS, and DRG codes based on established guidelines.
• Ensure documentation supports code selection and complies with regulatory and client-specific standards.
• Work collaboratively with internal teams and clinical documentation reviewers to resolve coding or documentation discrepancies.
• Maintain expected levels of accuracy and productivity in coding assignments.
• Keep current with changes in coding guidelines, payer rules, and regulatory requirements.
• Participate in regular quality checks, audits, and ongoing training to maintain performance standards.
• Utilize electronic medical records (EMRs) and coding tools efficiently and in line with privacy and data security requirements.

Qualifications:

• Associates or Bachelors degree in Health Information Management, Nursing, or a related field preferred.
• Certification required: CCS (Certified Coding Specialist), CIC (Certified Inpatient Coder), or equivalent.
• Minimum of 2 years of inpatient coding experience, with exposure to a range of hospital documentation styles.
• Strong knowledge of ICD-10-CM, ICD-10-PCS, MS-DRG/APR-DRG, and inpatient coding guidelines.
• Proficiency with EMR systems and encoder tools (e.g., 3M, Optum).
• Solid understanding of HIPAA and data confidentiality practices.

Preferred Skills:

• Background in coding for varied healthcare organizations or working with multiple provider systems.
• Excellent attention to detail, time management, and adaptability to different documentation formats.
• Effective communication skills and ability to collaborate with remote or cross-functional teams.