Under direct supervision, the Senior Inpatient Coder accurately codes hospital inpatient accounts for appropriate reimbursement, research, statistics, and compliance with federal and state regulations using established ICD-10-CM and ICD-10-PCS classification systems.
Key Responsibilities Serve as a clinical coding subject matter expert
Apply strong critical thinking skills to analyze and evaluate documentation issues in collaboration with medical staff, clinical staff, and clinical documentation specialists
Analyze, code, and abstract complex inpatient cases including trauma, rehab, neurology, and critical care using ICD-10-CM and ICD-10-PCS to ensure accurate APR-DRG, SOI, ROM, and POA assignment
Collaborate with senior coders and coding staff to share knowledge and provide guidance on complex cases
Monitor assigned workload daily to support timely billing processes
Code and abstract records within established turnaround times for each patient type
Maintain a coding accuracy rate of 90 percent
Maintain a productivity rate of 95 percent
Communicate with hospital departments regarding billing and registration issues and elevate concerns to management with clear documentation
Compose appropriate coding queries and work closely with CDI teams
Understand PPCs, MHACs, and PQIs and their financial and quality impact
Communicate with the auditing team to review findings and ensure accounts meet compliance standards
Adhere to AHIMA ethical coding standards and compliance guidelines
Support the University of Maryland Medical System mission, vision, values, goals, and policies
Perform other duties or projects such as coding corrections as assigned by management
Hours Operating hours are 6AM to 6PM EST
Flexible 8 or 10 hour shifts
40 hours per week within the operating timeframe
Required Qualifications High school diploma or equivalent
Formal ICD-10-CM and CPT training
Associate or Bachelor’s degree preferred
Minimum of 3 years of ICD-10-CM and ICD-10-PCS coding and abstracting experience in a Level 1 Trauma and Rehab hospital
Trauma coding experience is required
4 years of inpatient hospital medical record coding experience required
One of the following certifications is required
Certified Coding Specialist CCS
Registered Health Information Administrator RHIA
WORK ENVIRONMENT Must have their own equipment to work from
Must have reliable internet and a secure work environment
Must work EST or CST hours
We’re an equal opportunity employer and welcome all qualified applicants.
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