Inpatient Coder

Job Title: Inpatient Coder
Location: Upland, CA
Classification: Contract / Contract-to-Hire
Compensation: $30.00–$43.00/hr (DOE) 

Position Summary

Our client, an acute care hospital, is seeking an experienced Inpatient Coder to support its Health Information Management team. This position reviews inpatient medical records and assigns diagnosis and procedure codes that accurately reflect the patient’s hospital stay.

Responsibilities

• Review inpatient medical records, including provider notes, discharge summaries, operative reports, and supporting clinical documentation.

• Assign and sequence principal and secondary diagnoses using ICD-10-CM.

• Assign inpatient procedure codes using ICD-10-PCS.

• Apply present-on-admission indicators and validate appropriate DRG assignments.

• Identify documentation gaps and collaborate with clinical documentation improvement staff and providers to obtain clarification.

• Abstract required clinical information into electronic health record and coding systems.

• Resolve coding edits and participate in coding audits and quality reviews.

• Meet departmental accuracy, productivity, and turnaround expectations.

• Maintain patient confidentiality and comply with privacy and security requirements.

Qualifications

• Two to three years of recent inpatient coding experience in an acute care hospital.

• Active Certified Coding Specialist (CCS) certification through AHIMA or Certified Inpatient Coder (CIC) certification through AAPC.

• Strong knowledge of ICD-10-CM, ICD-10-PCS, and inpatient coding guidelines.

• Experience with DRG methodology, principal diagnosis selection, and present-on-admission reporting.

• Working knowledge of medical terminology, anatomy, physiology, and disease processes.

• Experience using electronic health records and coding or encoder software.

• Strong analytical skills, attention to detail, and ability to communicate documentation questions clearly.