Inpatient Medical Coder

Responsible for reviewing multidisciplinary inpatient medical records and health information in order to classify patient diagnoses and procedures by accurate ICD-10-PCS codes and DRGs. is used only for inpatient, hospital settings in the US (87,000 codes)

• Evaluate documentation of patient care to code and abstract data used for statistics, state reporting, and insurance reimbursement.

• Assign ICD-10-CM codes to inpatient diagnoses, treatments and procedures according to coding guidelines.

• Complete coding with an error rate within the work standard and maintains standards relative to productivity and quality. After roughly first 90 days, you are expected to do 25-30 admission, concurrent, and discharge coding records per day with a 95% or better.

• Communicate verbally and in writing with physicians, medical staff and other care professionals when documentation needs clarification for accurate code assignment which may or may not impact reimbursement.

• Prepare workload reports and participate in department management studies, as well as data quality reviews or other documentation audits.

• Help train and orient new coders.

• Perform peer review of codes and DRG assignment.

• Keep knowledge of coding and DRG assignment current by reviewing federal publications and other reference materials for changes in regulations and practice guidelines.

• Monitor compliance with documentation standards required for accurate and thorough coding

• Investigate, evaluate and identify opportunities for documentation improvement

• Provide guidance to hospital CEOs, medical staff and others regarding compliant documentation practices required for accurate reimbursement and statistics

(Please note: This job is NOT remote but on-site in Mechanicsburg, PA)