Position Overview
Our client is seeking a detail-oriented Inpatient Coder Analyst to accurately code inpatient hospital encounters while ensuring compliance with federal regulations, payer guidelines, and organizational standards. This individual will play a key role in supporting appropriate reimbursement, maintaining coding quality, and collaborating with clinical documentation and revenue cycle teams.
The ideal candidate has strong experience with inpatient acute care coding, a thorough understanding of ICD-10-CM/PCS coding guidelines, and the ability to work independently while partnering with physicians and clinical staff to ensure complete and accurate documentation.
Responsibilities
- Review and assign accurate diagnosis and procedure codes for acute care inpatient, skilled nursing facility (SNF), and rehabilitation medical records.
- Code inpatient encounters using ICD-10-CM, ICD-10-PCS, and other applicable coding classification systems in accordance with regulatory and payer requirements.
- Perform coding for ambulatory, emergency department/urgent care, interventional radiology, and same-day surgery records as needed.
- Review the complete medical record to ensure accurate code assignment and appropriate reimbursement.
- Analyze documentation for completeness, accuracy, and compliance with federal, state, and organizational coding guidelines.
- Initiate physician queries to obtain clarification when medical record documentation is incomplete, conflicting, or insufficient for accurate code assignment.
- Collaborate closely with physicians, Clinical Documentation Improvement (CDI) specialists, and revenue cycle teams to improve documentation quality and coding accuracy.
- Actively participate as a member of the Clinical Documentation Improvement (CDI) Team, supporting documentation initiatives and coding education.
- Maintain productivity and quality standards while meeting established coding turnaround times.
- Stay current on coding regulations, reimbursement methodologies, and industry best practices.
Qualifications
- Certified coding credential required (RHIA, RHIT, CCS, CIC, or equivalent preferred).
- Experience coding acute care inpatient medical records required.
- Strong knowledge of ICD-10-CM, ICD-10-PCS, CPT, and official coding guidelines.
- Experience with physician query processes and clinical documentation improvement initiatives.
- Understanding of MS-DRGs, reimbursement methodologies, and regulatory compliance requirements.
- Ability to analyze complex medical records with exceptional attention to detail.
- Strong written and verbal communication skills with the ability to collaborate across multidisciplinary teams.
- Proficient with electronic health records (EHR) and coding software.
- Ability to prioritize workload, work independently, and consistently meet productivity and quality expectations.
