Inpatient Coder - Full‑time with Benefits Job Category: Admin/Clerical Requisition Number: CODER012234 Full‑time Overview Supports and incorporates Frederick Health (FH) mission, vision, core values and customer service philosophy into daily performance, adhering to the FH Compliance Program and all regulatory requirements and the FH Standards of Behavior. Codes and abstracts inpatient medical records of all types, performing rigorous reviews of clinical documentation to assign appropriate ICD‑10‑CM/PCS code sets and the correct APR‑DRG within the hospital information system. May also code other work types as assigned by the Coding Manager. Essential Functions Determines the correct principal diagnosis, identifies and assigns comorbidities and complications, secondary diagnoses, present‑on‑admission indicators for ICD‑10‑CM and Maryland Hospital Acquired Conditions (MHACs), principal procedure codes and secondary procedure codes. Assigns the appropriate APR‑DRG. Works with Clinical Documentation Improvement (CDI) to ensure MHACs and Prevention Quality Indicators (PQIs) are correctly assigned. Identifies and correctly codes and sequences ICD‑10‑CM/PCS diagnoses and procedure codes for optimal reimbursement. Consults with and educates physicians on coding practices and conventions to provide detailed coding information. Protects confidential medical information following HIPAA guidelines. Accurately abstracts attending physician, discharge disposition, location discharged to, consultations, ambulance run number & county codes, dates of surgery or other procedures, cause of death if applicable, and anesthesiologist information. Writes compliant queries to physicians when documentation is unclear or incomplete. Participates in an Abstract Peer Review to verify abstract element accuracy. Collaborates with registration, patient financial services, lab, pathology, and medical records departments. Participates in special projects such as the aging report or denial review. Meets daily productivity standards per Coding Productivity Standards. Maintains a thorough understanding of anatomy, physiology, medical terminology, disease processes, and surgical techniques through continuing education, applying ICD‑10‑CM and CPT guidelines to inpatient and outpatient diagnoses and procedures. Identifies the correct location in the medical record to obtain pertinent information such as BMI, hemodialysis, blood transfusion, pressure ulcers, isolation, mechanical ventilation, and orders. Keeps up‑to‑date on HSCRC guidelines and state and national coding updates. Maintains knowledge of medical record practices, standards, regulations, Joint Commission on Accreditation of Health Organizations (JCAHO), and HSCRC. Required Knowledge, Skills and Abilities PC experience; ability to use computer terminals for prolonged periods to enter data. Ability to work under time and productivity constraints. Ability to work with frequent distractions/interruptions. Ability to read records and handwriting of varying legibility for prolonged periods. Good organizational skills. Ability to sit for prolonged periods. Ability to reach, bend, lift, and carry medical records. Good public relations and communication skills. Good judgment when dealing with others. Minimum Education, Training, and Experience Required High School Diploma or GED required; completion of a Coding Certificate Program required. At least one of the following credentials: CCS (Certified Coding Specialist), RHIA, or RHIT. Five to ten years of hospital coding experience, including inpatient coding or a mix of inpatient and outpatient coding using ICD‑10‑CM and CPT, is preferred. Demonstration of skills through a hospital‑administered advanced coding test with a satisfactory score. Benefits Frederick Health offers a comprehensive and affordable benefits package. Health, dental, and vision insurance are available the first of the month after 30 days of employment for employees working at least 20 hours per week, with multiple plans to best meet individual and family needs. Life insurance, short‑term income replacement, and long‑term disability are employer‑paid for eligible employees. A robust paid time‑off program, a 403B retirement plan with an employer match, free financial planning sessions, an educational assistance program, and an employer‑paid employee assistance program are also available. Compensation Pay is based on experience, skills, and education. If the position is part‑time, salary is prorated based on scheduled hours. The pay range may vary within the stated range based on specialty if applicable. Non‑exempt positions may have shift differential and/or overtime paid, if applicable. Hourly pay range: $26.46–$37.80 Hours: Monday‑Friday, 8:00 am–4:30 pm or flexible Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor. #J-18808-Ljbffr