Job Title: Inpatient Coder
Job Tenure : 13 weeks
Location: 100% remote
Shift: flexible but cannot work between 6p & 7p EST
contract is FT (40 hours per week) with the potential for contract to hire at the conclusion of the contract, if the candidate performance and need align

***Due to the potential contract to hire nature of the position, candidates for the FT role must be from one of the following states***
Maryland
Pennsylvania
Virginia
West Virginia
District of Columbia



JOB SUMMARY: Following established conventions and guidelines, codes and abstracts the medical records of inpatients. Groups codes to determine diagnosis related groupings (DRGs - CMS and/or APR). Primarily handling non-trauma but still very complex IP records. May also be asked to code day surgery, emergency and outpatient records. Meets departmental accuracy and production standards of 2 charts per day with 98% accuracy.

RESPONSIBILITIES:
CODES - Reviews medical records to determine the physician's diagnosis/procedures for the patient and assigns ICD-10CM/PCS codes to those diagnoses/procedures.
Tasks:
Reviews the entire medical record for codeable information.
Writes queries as appropriate and adheres to the query policy. Follows-up on queries and updates coding and the query as appropriate and in a timely manner.
Assigns the appropriate APR/DRG.
Is familiar with and follows the Coding Compliance plan.

ABSTRACTS - Abstracts predetermined information from inpatient, day surg, ER, and outpatient records and enters that information on to the medical record abstract.
Tasks:
Enters appropriate information on the abstract as determined by departmental policy.
Completes and releases to billing abstracts that are ready to be billed.

COMMUNICATES - Assures that co-workers and management are well informed and adequately prepared by communicating information relevant to the coding area or department.
Tasks:
Prepares and submits a properly completed management report to the Manager weekly.
Notifies the Manager and/or Coordinator of charts with missing documents. Notifies admitting of registration errors.
Works with Clinical Documentation Specialists to develop a good working team.
Communicates about queries and query responses. Uses CDI as a resource for clinical information.
Participates in department meetings, inservice, and peer interviews (as requested). Assists with the training of new employees and students as requested.
Ensures that emails, audits, queries and reports are processed timely.

RESEARCHES - Researches to ensure that records are coded, grouped and abstracted properly.
Tasks:
Contacts other departments to obtain information needed for coding such as diagnoses, procedures, treatments rendered, etc.
Contacts physicians to obtain information (diagnoses, procedures, treatments, clarifications) needed for coding.
Utilizes references (dictionaries, Coding Clinics, CPT assistant, Coding Policies, other literature, Clinical Documentation Specialists, Coordinator, Internal Auditor, etc) to help determine appropriate codes.

MINIMUM REQUIREMENTS:
Formal working knowledge equivalent to an Associate's degree (2 years college) in HIM, HIT or related field
3-5 years of relevant coding experience
CCS or CCA with 5+ years' experience or RHIT, or RHIA required.
Must complete 2 charts per day with 98% accuracy
Ortho coding experience preferred