Inpatient Coder

• Assigns International Classification of Diseases (ICD)-10-CM Clinical Modification (CM) and ICD-10-Procedure Coding System (PCS) codes creating diagnosis-related group (DRG) assignments. Abstracts pertinent information from patient records.
• Sequence the diagnosis and procedures using coding guidelines and optimizing the DRG as applicable.
• Addressing all edits, including but not limited to nosology, Exihauser, Patient Safety Indicators (PSI), hospital-acquired condition (HAC), and others as needed based on quality indicator.
• Apply reason/tracking code and rationale (if needed) in 3M as needed for DRG mismatches on Clinical Documentation Improvement (CDI) reviewed cases.
• Queries physicians when code assignments are not straightforward or documentation in the record is inadequate, ambiguous or unclear for coding purposes.
• Apply present on admission (POA) indicators on all inpatient charts.
• Keeps abreast of coding guidelines and reimbursement reporting requirements, new technology and procedures as well as CMS approved clinical trials. Brings identified concerns to the supervisor or department manager for resolution.
• Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines.
• Data enters coded/abstracted information for DRG assignment into the HMH designated computer system.
• Review Case Management notes and assign discharge disposition based on the disposition indicated by CM or email leadership when not present and or conflicting.
• Identifying missing operative/path reports/or any pertinent procedures in patients records at the time of coding. Notifying Discharged not final billed (DNFB) of missing reports required for coding.
• Participate in ongoing coding educational webinars routinely and as needed.
• Participate as needed in external departments and/or Contract vendors review/educational sessions to comply with legal and procedural policies, optimize reimbursement and adhering to regulations.
• Review individually audited cases by third party companies and provide a rebuttal if needed.
• Other duties and/or projects as assigned.
• Adheres to HMH Organizational competencies and standards of behavior.

• High School diploma, general equivalency diploma (GED), and/or GED equivalent programs.
• Minimum of 3+ years of experience coding in an acute complex healthcare environment.
• Demonstrated expertise in Medical Terminology, Anatomy and Physiology, Pathophysiology, Pharmacology and inpatient coding.
• Encoder usage required with proficiency in computer skills.
• Excellent written and verbal communication skills.
• Proficient computer skills including but not limited to Microsoft Office and Google Suite platforms.

• Associate's level degree or higher in HIM, Allied health, or another related field.

• Certified Coding Specialist.

• Registered Health Information Administrator (RHIA) or Registered Health Information Technician (RHIT), or other Allied Health credential with inpatient coding experience.

Hackensack Meridian Health