Benchmarking, Clinical Data, Content Management Systems (CMS), Documentation, HIPAA (Health Insurance Portability and Accountability Act), Health Information Management, Hospital, ICD-10, Identify Issues, Medical Coding, Medical Record System, Medical Records, Patient Care, Quality Assurance, Quality Management, Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT), Regulations, Regulatory Requirements
Please Note:
- It is a Fully Remote position.
- Location: Remote
- City/State: Baltimore, Maryland
- Position Type: Contract / Travel
- Department: Health Information Management (HIM)
- Schedule: Full-time
- Fully remote position
- Ability to work independently in a remote environment (must have their own equipment)
- Must be based in EST or CST hours
JOB SUMMARY
The Inpatient Coder is responsible for reviewing inpatient medical records and assigning accurate ICD-10-CM and ICD-10-PCS codes in accordance with official coding guidelines, regulatory requirements, and Clint policies. This position supports timely and accurate billing, reimbursement, and compliance, and is fully remote.
ESSENTIAL RESPONSIBILITIES
- Review inpatient medical records to assign appropriate ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes
- Ensure coding accuracy and compliance with AHIMA, AHA, CMS, and official coding guidelines
- Abstract clinical data accurately into the coding system
- Meet established productivity and quality benchmarks
- Identify documentation issues and work with CDI or providers as appropriate
- Maintain confidentiality and comply with HIPAA regulations
- Participate in audits, education, and quality improvement initiatives as required
- Stay current with coding updates, regulatory changes, and payer requirements
Requirements
REQUIRED QUALIFICATIONS
- Active coding certification (RHIT, RHIA, or CIC) required
- Minimum of 4+ years of recent inpatient hospital coding experience required
- Minimum of 3 years ICS-10-CM/ICD-10-PCS coding and abstracting experience with a Level 1 trauma and rehab hospital or 4 years of experience with coding inpatient hospital medical records required
- Strong knowledge of ICD-10-CM and ICD-10-PCS coding guidelines
- Experience coding complex inpatient hospital cases
- Proficiency with encoder and EHR systems preferred
- Ability to work independently in a remote environment (must have their own equipment)
PREFERRED QUALIFICATIONS
- Experience with Epic or 3M encoder preferred
- Experience working in an academic or large health system setting preferred