Inpatient Coder

Job Summary

The Inpatient Coder is responsible for accurately coding and abstracting diagnoses, procedures, and clinical information from inpatient medical records. This individual ensures compliance with established coding guidelines while maintaining high standards of data quality, integrity, productivity, and accuracy.

Essential Responsibilities

The Inpatient Coder plays a key role in ensuring accurate and compliant coding of inpatient medical records. Responsibilities include, but are not limited to:

• Assign ICD-10-CM/PCS diagnosis and procedure codes in accordance with Official Coding Guidelines, AHA Coding Clinic, CMS, and other regulatory requirements.
• Apply Uniform Hospital Discharge Data Set (UHDDS) definitions to determine principal diagnoses, secondary diagnoses, and procedures.
• Utilize MS-DRG and APR-DRG reimbursement methodologies to ensure accurate code assignment.
• Assign Present on Admission (POA) indicators for inpatient diagnoses.
• Identify and accurately code Hospital-Acquired Conditions (HACs) supported by physician documentation.
• Verify patient data and discharge disposition to ensure coding compliance.
• Prepare compliant physician queries to clarify conflicting or incomplete documentation following current industry guidelines.
• Abstract required clinical information into coding and abstracting systems.
• Review and resolve coding edits, pre-bill edits, and missing documentation to support timely billing.
• Collaborate with Health Information Management (HIM) staff and Clinical Documentation Improvement Specialists (CDIS) to ensure complete and accurate documentation.
• Utilize electronic medical record (EMR), coding, and abstracting software to meet established productivity and quality standards.
• Participate in continuing education and maintain required coding certifications and CEUs.

Minimum Qualifications

• Minimum of 5 years of inpatient coding experience using ICD-10-CM/PCS.
• Extensive experience with MS-DRG and APR-DRG reimbursement methodologies.
• AHIMA certification preferred (RHIA, RHIT, CCS, or equivalent).
• Associate's degree or higher in Health Information Management or a related field preferred.
• Experience coding within a large acute care hospital system (500+ beds).
• Experience with Epic EMR and 3M coding software preferred.
• Experience coding complex acute care cases, including:
  • Level I Trauma
  • Teaching hospitals
  • Kidney, Liver, and Pancreas Transplants
  • General Surgery
  • Orthopedics
  • Cardiothoracic Surgery
  • Vascular Surgery
  • Bariatric Surgery
  • Gynecology
  • Neurology
  • Urology
  • Colorectal Surgery
  • Behavioral Health
  • Gastroenterology
  • Wound Care
• Ability to consistently meet coding productivity and accuracy standards.
• Successful completion of a pre-employment coding assessment.

Physical Requirements

• Ability to remain seated for extended periods while working at a computer.
• Frequent use of a computer, keyboard, and other office equipment.
• Strong verbal and written communication skills.
• Ability to review electronic medical records and other digital documents for extended periods.
• Occasional movement within the workspace to access office equipment or materials.

Work Environment

• Dedicated, secure, and distraction-free home office or workspace that protects patient confidentiality (PHI).
• Reliable high-speed internet connection (minimum 200 Mbps).
• Professional home office environment suitable for remote work.

Nesco Resource offers a comprehensive benefits package for our associates, which includes a MEC (Minimum Essential Coverage) plan that encompasses Medical, Vision, Dental, 401K, and EAP (Employee Assistance Program) services.

Nesco Resource provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.