Steward Health Care System
TITLE: Inpatient Coder
JOB CODE / GRADE: ADS-1698
DEPARTMENT: HIM/Coding/CDI Operations
FLSA STATUS: Non Exempt
REPORTS TO: Inpatient Coding Manager
(Briefly describe the overall purpose of this position - Why does it exist and how does it contribute to the overall organization?)
Responsible for assigning diagnostic and procedural codes to patient charts of moderate to high complexity using ICD-10-CM and ICD-10-PCS or any other designated coding classification system in accordance with coding rules and regulations. Abides by the Standards of Ethical Coding as set forth by AHIMA. Abstracting required clinical information from the medical record.
(Use bullets for specific responsibilities)
- Reviews medical records for the determination of accurate assignment of all documented diagnoses and procedures. Adheres to Standards of Ethical Coding (AHIMA).
- Reviews medical records to determine accurate required abstracting elements including appropriate discharge disposition.
- Demonstrates ability to achieve 95% or higher accuracy and consistency in the selection of principal and secondary diagnoses and procedures.
- Knowledge of MS-DRG and APR DRG classification and reimbursement structures
- Stays current with AHA Official Coding and Reporting Guidelines, CMS and other agency directives for ICD-10-CM and ICD-10-PCS coding.
- Attends mandatory coding seminars on annual basis for inpatient coding. Quarterly review of AHA Coding Clinic. Attends Quarterly Coding Updates and all coding conference calls
- Communicates and resolves coding issues (lacking documentation, physician queries, missing documentation, second level review, DRG reconciliation, etc.) for appropriate follow-up and resolution
- Candidate must display a superior knowledge of Coding Guidelines (Coding Clinic, UHDDS Official Coding Guidelines, CCI Edits).
- Comprehensive understanding of CCs/MCCs, impact on quality reporting, UHDDS guidelines, HACs and PSIs
- Analytical Skills that include effective evaluation, synthesis and use of information gathered
- Works collaboratively with CDI, Quality, and other facility(ies) leadership
- Experience with compliant physician querying writing
- Candidate must be self-motivated, display a high level of computer literacy, excellent verbal, and written communication skills, able to meet assigned deadlines, and organized
- The position will report to the HIM Inpatient Coding Manager
- Ability to meet coding productivity standards
REQUIRED KNOWLEDGE & SKILLS:
(Examples: Ability to work independently and take initiative; Good judgment and problem-solving skills; Communication skills; Interpersonal and organizational skills; Level of confidentiality)
- One to three years’ experience performing medical record coding in acute care setting required
- High school graduate or equivalent is required.
- Associate of bachelor’s degree in Health Information, Nursing, or other related field, or formal coding classes completed and passed preferred. Years of coding experience will be considered in lieu of education requirements.
- Meditech experience preferred. Functional Knowledge of EMR (Electronic Medical Record), Encoder and CDI Tools and other Support Software
- Microsoft Office (Word, One Note, Excel, Outlook, PowerPoint)
- Excellent verbal and written communication skills
- Ability to meet assigned deadlines.
- Education: RHIT or RHIA preferred
- Experience: 1 - 3 year of Acute Inpatient Coding Experience
- Certification/Licensure: AHIMA or AAPC approved credential
- Software/Hardware: 3M experience required
- Other: Remote position
WORKING CONDITIONS: (Place X's where applicable)
Amount of Time Spent
Up to 25%
Use Hands to Finger, Feel, Reach w/Hands & Arms, Climb, or Balance
Stoop, Kneel, Crouch, or Crawl
Talk or Hear
Taste or Smell
Amount of Pounds
Amount of Time
Up to 25%
75% or More
Up to 10 lbs.
Up to 25 lbs.
Up to 50 lbs.
Up to 100 lbs.
Over 100 lbs.
Ability to Adjust Focus
Exposure to the following environmental conditions
Amount of Time Spent
Up to 25%
Outdoor Weather Conditions
Extreme Cold (Non-Weather)
Work in High Precarious Place
Risk of Electrical Shock
Risk of Radiation
Flammable, Explosive Gases
Toxic or caustic Chemicals
Dust or Other Irritants
Grease or Oils
Infections From Disease Bearing Specimens
Hot or Noisy Equipment
Humid or Wet Conditions (Non-Weather)
Level of Noise that is Typical in the Work Environment
Safety Equipment Used When Performing This Job:
Filter Lens (Welding/Soldering):
Other: (List Below)
Ear Plugs or Mufflers:
I have been given a copy of this position description and have read and will comply with the expectations and requirements outlined in this position description.
Employee Name: _____________________________________________
Employee Signature: __________________________________________
Manager Name: ______________________________________________
Manager Signature: ___________________________________________
Disclaimer: The above information on this description has been designed to indicate the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of employees assigned to this job.