Inpatient Coder - Fully Remote

GENERAL SUMMARY : Ensures proper assignment of diagnosis and procedure codes, along with validating and adjusting charges according to the services the patient received.

Works collaboratively with Clinical Documentation Improvement personnel to ensure coding is clinically supported.

Participates in the identification and resolution of discrepancies in documentation; assists in training as necessary.

Maintains a working knowledge of applicable coding and reimbursement Federal, State, and local laws and regulations, the Compliance Accountability Program, Code of Ethics, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

Participates in quality assessment and continuous quality improvement activities.

Performs all job duties and responsibilities in a courteous and customer-focused manner according to the Hurley Family Standards of Behavior.

SUPERVISION RECEIVED : Works under the general supervision of the Clinical Coordinator and/or Director of Coding and Clinical Documentation Improvement (CDI).

• Assigns diagnostic and procedural codes to patient's clinical records using ICD-10-CM and ICD-10-PCS coding systems for reimbursement purposes and for Hurley Medical Center's automated information system: Responsible for inpatient coding as assigned.
• Determines DRG assignment through input of diagnostic codes, procedural codes and abstracted data into the computer system: Follows up to ensure accuracy of DRG assignment for cases submitted for reimbursement.
• Abstracts specific data elements after thorough review of each medical record.
• Designates principal diagnosis and procedure on complex cases requiring independent action and judgment; assists in monitoring the completeness, accuracy and consistency of the principal diagnosis, related diagnoses and procedures.
• Interprets health record documentation using knowledge of anatomy, physiology, clinical disease process, pharmacology, and medical terminology to determine the Principal Diagnosis, secondary diagnoses, and procedures. Screens medical records to ensure completeness in line with record content guidelines such as Present On Admission (POA) indicators and discharge disposition.