Inpatient Medical Record Coder

Summary of Position

We are looking for an experienced Inpatient Medical Record Coder to accurately code inpatient medical records for reimbursement, clinical data accuracy, research, utilization review, and regulatory reporting purposes.

The Inpatient Medical Record Coder will be responsible for reviewing and coding complex inpatient medical records, identifying coding opportunities, suggesting improvements, monitoring trends, and addressing discrepancies as needed. This role requires a strong understanding of inpatient coding guidelines, reimbursement methods, and practices in acute-care hospital settings.

Educational Background & Experience

• High school diploma or equivalent.

• At least 3 years of inpatient coding experience in an acute-care hospital required.

Required Certification

Applicants must hold one of the following certifications:

• Certified Coding Specialist (CCS)

• Registered Health Information Administrator (RHIA)

• Registered Health Information Technician (RHIT)

Key Knowledge & Skills

• Proficiency in ICD-10-CM/PCS, CPT, HCPCS, and ICD-9-CM code sets.

• Understanding of Medicare inpatient hospital and IPPS reimbursement regulations.

• Knowledge of MS-DRG classification and reimbursement methodology.

• Familiarity with current inpatient coding guidelines, healthcare regulations, and electronic health record systems.

• Experience with revenue cycle workflows, including charges, code edits, audits, denials management, and clinical documentation improvement.

• Understanding of medical terminology, anatomy, disease processes, and surgical procedures.

• Awareness of healthcare laws, regulations, patient privacy requirements, and hospital policies.

Skills & Responsibilities

• Accurate and efficient coding and abstraction of inpatient medical records.

• Reviewing medical documentation for completeness, consistency, and accuracy.

• Identifying coding discrepancies, trends, and areas for enhancement.

• Addressing coding-related denials and conducting necessary follow-up.

• Performing data collection, manipulation, retrieval, and analysis.

• Running queries and creating technical reports.

• Utilizing 3M 360 or similar integrated encoder/computer-assisted coding systems.

• Maintaining strict confidentiality of patient and organizational information.

• Working independently with attention to detail and accuracy.

• Effectively communicating coding issues, findings, and recommendations to stakeholders.

• Establishing and nurturing positive relationships across departments.