Hiring || Senior Associate Inpatient Coders || Innova Solutions

Role & responsibilities

Medical Coder Job Summary:

Under the general direction of the Inpatient Coding Supervisor, the Medical Coding Specialist - Inpatient reviews documentation in the electronic medical record and assigns and sequences ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes, in accordance with the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and in compliance with ICD-10 Official Coding Guidelines and other regulatory requirements. The Medical Coding Specialist I - Inpatient will use Diagnosis Related Groups (DRG) methodologies, including Medicare Severity DRGs (MS-DRGs) and All Patient Refined DRGs (APR-DRGs). The Medical Coding Specialist - Inpatient will perform physician queries, will clarify documentation, and will participate in the DRG reconciliation process in collaboration with the Clinical Documentation Integrity Specialist (CDIS) team. The Medical Coding Specialist - Inpatient will partner with the Inpatient Coding Quality Analysts(Internal and external Auditors) and the Inpatient Coding Supervisor for education and quality monitoring.

Roles and Responsibilities of Medical Coder:

• APR-DRG Experience is mandatory.
• Certification- Either CCS or CIC is mandatory. 
• Review, analyze and interpret the entire electronic medical record for the current admission to identify all diagnoses and procedures documented during the admission.
• Determine and assign the principal and significant secondary ICD-10-CM diagnosis codes, in addition to present on admission indicators, and ICD-10-PCS procedure codes, using official coding guidelines and knowledge of anatomy and physiology, pharmacology and pathophysiology/disease processes.
• Identify cases with clinical indicators that may require provider documentation clarification and/or specificity in order to accurately assign codes; collaborate with CDIS team as part of the clinical documentation validation and physician query workflows.
• Analyze code assignment and sequence to assure proper DRG assignments; sequence codes in compliance with ICD-10 Official Coding Guidelines, Uniform Hospital Discharge Data Set (UHDDS) and other regulatory requirements to accurately assign the DRG.
• Analyze the medical record documentation for complications and comorbidities
• Analyze medical record documentation for optimum severity of illness and risk of mortality scores
• Confirm Admission-Discharge-Transfer (ADT) information and correct when necessary
• Suggest and assist with workflow process improvements as appropriate. Participate in coding quality and productivity processes.
• Strictly follow HIPPA regulations to maintain patient data confidential.

Shift - 12 PM - 9 PM (Both Side cabs)

5 days working from office