Inpatient Coder Large Acute Care Hospital System

Job purpose

The Inpatient Auditor will provide assistance with all related activities, including auditing of facility inpatient charts. Inpatient Auditor will also review medical record encounter to ensure that assigned codes meet required coding guidelines.

Duties and responsibilities

Review assigned ICD10 CM Diagnosis Codes and ICD 10 PCS Procedure Codes for assigned accounts.

Review the selected and sequenced principal and secondary diagnosis and procedure codes.

Review assigned DRG to ensure it is appropriate.

Review the medical record and all applicable documentation to determine the appropriate codes were assigned for the services and diagnoses and document findings in an excel spreadsheet and / or auditing tool.

Be knowledgeable of billing and coding requirements for governmental guidelines and private insurance payers.

Review the abstract of statistical data from the patient record and enter information following the facility guidelines.

Utilize coding resources along with any other applicable reference material available to ensure accuracy in coding for all of the assigned services.

Review documentation of various providers to determine accurate coding for all medical services and surgical procedures from available medical records within electronic medical records.

Review to determine if the diagnosis is unclear prepare and assign queries following the facility guidelines for the query process.

Identify missed query opportunities.

Determine that all appropriate diagnoses were assigned to the most specific ICD-10 code.

Assist other departments in coding and reimbursement issues.

Follow all HIPAA regulations and uphold a higher standard around privacy requirements.

Develop trusted relationships with the client contacts and other team members around the globe.

Adhere to all internal competencies, behaviors, policies and procedures to ensure efficient work processes.

Completes all assigned work in a timely manner based on internal, client and / or payer standards.

Maintain at least a 95% accuracy rate at all times.

Maintain productivity standards, tracking and deadlines.

Maintain and complete accurate productivity and tracking logs.

Keep all equipment updated and active on the internet.

Comply with established facility policies and procedures.

Skills and Qualifications

High school or GED required.

Associates or Bachelors in Health Information preferred

Graduate of an approved certified coding program required or equivalent experience.

Certification requirements : CCS

The candidate must have at least 5 years or more of recent inpatient medical coding experience at a large (300+ beds) acute care facility and be certified.

Large Facility Experience, Trauma experience, teaching facility experience. Experience with coding orthopedics, cardiology, and neurology.

Thorough knowledge of ICD 10 CM and CPT coding principles and rules, Coding Clinic Guidelines and Coding Compliance

Current Continuing Education Credits.

Productive and Accurate

Working knowledge of disease processes, MS-DRG and APC classification and reimbursement structures, applicable coding edits and general knowledge of Local Coverage Decisions as it relates to coding and billing

Effective written and verbal communication skills

Experience with encoder technology, computerized abstracting systems, and electronic medical record systems

Ability to work independently

Microsoft Office proficient a MUST; especially Excel.

Working conditions

This job operates in a remote setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines

This position does not require travel at this time.

Physical requirements

Must be able to sit and / or stand for up to 8 hours a day.

The worker is required to have close visual acuity to perform an activity such as : preparing and analyzing data and figures; transcribing; viewing a computer terminal; extensive reading; visual inspection involving small defects.

Direct reports

This position does not have any direct reports at this time.