Inpatient Medical Records Coder

Position Summary: Codes accurately and productively with abstraction to assigned inpatient medical records to meet the reimbursement, indexing and statistical requirements of the hospital. Consistently maintaining production and accuracy standards at all times.

Essential Duties and Responsibilities:

• Accurately codes and sequences all diagnoses and procedures documented in the medical record according to the established official coding guidelines, principles and appropriate reimbursement standards
• Utilizes Computer Assisted Coding software program following assigned workflows
• Accurately abstracts required data entering into Computer Assisted Coding system
• Works with Clinical Documentation Improvement Specialists to assure clear, concise and specific documentation from physicians when clarification is needed
• Issues accurate coding queries following AHIMA compliant coding query guidelines and assisting medical staff member documentation clarification
• Ability to meet and sustain Silver Cross Hospital production and quality standards for IP coding, post training.
• Assists with special projects and reports as requested
• Promotes a clean and safe environment of care, utilizing the SAFE error prevention habits
• Provides the highest standard of privacy and confidentiality in matters involving patients, coworkers and the hospital by abiding by the Standards of Conduct

Required Qualifications:

Education and Training:

• Registered Health Information Technologist (RHIT); or Registered Health Information Administrator (RHIA); or Certified Coding Specialist (CCS) required
• MS-DRG knowledge required, APR-DRG knowledge a plus
• 2 – 3 years of Acute Care Hospital Coding experience required
• 3M Encoder experience preferred, Cerner, Meditech, Optum System experience preferred