Inpatient Coder II

Position Summary:
The Inpatient Coder II is the second level coding position in a 3-tier career ladder. Inpatient Coder IIs will evaluate inpatient medical records and accurately assign the appropriate ICD-10 CM/PCS codes, Present on Admission (POA) indicators, and relevant DRGs. The Coder II must be skillful in the identification and assignment of all diagnoses and procedures in accordance with nationally recognized coding guidelines, as well as researching opportunities to improve documentation.

Primary Responsibilities:

• Assigns appropriately sequenced and compliant ICD-10 CM/PCS codes as documented in the electronic medical record (EMR).
• Applies definition of principal diagnosis for proper assignment of MS-DRGs, APR-DRGs, and POA indicators using a designated encoder/grouper, while ensuring compliance with nationally established coding guidelines.
• Utilizes selected encoder and/or computer-assisted coding software (CAC) set forth by client and Accuity. Abstracts pertinent data from documentation in accordance with client, state, and federal reporting requirements.
• Identifies instances in which provider clarification is necessary to ensure quality, completeness of documentation, and optimal, compliant reimbursement and communicates to appropriate channels.
• Updates and/or recommends coding changes as necessary due to additions or revisions in physician documentation and Internal Controls and Quality.
• Maintains required standards of performance in both coding accuracy and productivity to meet client turnaround and satisfaction.
• Records accurate production logs, time keeping, and other relevant tracking information daily.
• Performs additional job-related duties as assigned from coding management within pre-determined schedule.
• Stays current with most recent coding changes and guidance from CMS, AHA Coding Clinics, AHIMA, Official Inpatient Coding Guidelines, as well as internal education from Physicians, CDI and Coding leadership.
• Completes required Continuing Education hours to maintain credential requirements.
• Participate in Coding department meetings and other events as assigned.
• Maintains a collegial working relationship with other departments.
• Accepts coaching, training, and education on a routine basis as needed.

Position Qualifications:
Education:

• Minimum HS Diploma or GED required
• Coding credential required from AHIMA (RHIA, RHIT, CCS) or AAPC (CPC, CIC)
• Associate’s or bachelor’s degree in HIM or coding preferred

Experience:

• Minimum 5 years of current Inpatient facility coding experience; minimum 2 years Level 2 trauma center and/or 2 years academic teaching medical center
• Extensive knowledge of ICD-10 guidelines and coding regulations
• Demonstrated knowledge in DRG methodologies and compliant reimbursement practices

Knowledge, Skills, and Abilities:

• Proficiency in utilizing a variety of EMR systems, EPIC experience preferred
• Independently research coding questions and utilize Accuity’s internal educational resources
• Ability to use a PC in a Windows environment, including MS Word, MS Excel, MS Teams
• Autonomous, focused individual able to work remotely or on-site in a rapidly growing organization

Physical Requirements:
The requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job with or without reasonable accommodations.

Unless otherwise indicated, Accuity positions require interaction with people and technology while either sitting or standing. Employees must be able to communicate via phone, email, etc. and sit for extended periods of time, with or without reasonable accommodations. Physical effort and exposure to physical risk are limited to that of an office role environment.

While this job description is intended to be an accurate reflection of the job requirements, management reserves the right to modify, add or remove duties from a job and to assign other duties as necessary and at any time. All positions at Accuity are at-will employment, and a position description is not a guarantee of a job or of job responsibilities.