IN-PATIENT MEDICAL CODER

Employment Type: Full-time

Job Summary

The Medical Coder will be responsible for reviewing patient medical records, analyzing provider documentation, and accurately assigning diagnosis and procedure codes in accordance with established coding guidelines and regulations.

The successful candidate should have strong inpatient hard-coding experience, particularly with ICD-10-CM and ICD-10-PCS, as well as experience with DRG, POA, CC/MCC, and coding compliance.

Key Responsibilities

• Review and analyze inpatient medical records and provider documentation.
• Assign accurate ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes.
• Determine the appropriate Principal Diagnosis and Secondary Diagnoses.
• Identify and accurately code Comorbidities and Complications (CC) and Major Comorbidities and Complications (MCC).
• Assign the appropriate Present on Admission (POA) indicators.
• Assign accurate Diagnosis-Related Groups (DRG).
• Review medical records for coding compliance and adherence to official coding guidelines.
• Code inpatient and day surgery cases based on client and organizational requirements.
• Prepare compliant provider queries when additional documentation or clarification is required.
• Enter coding and abstracted patient information into the appropriate encoder and computer systems.
• Identify and report coding and documentation concerns to the supervisor.
• Maintain strict confidentiality of patient medical records.
• Monitor and meet the required minimum 95% quality and productivity targets.

Qualifications

• At least 2 years of relevant inpatient medical coding experience, particularly inpatient hard-coding.
• Revenue Cycle Management (RCM) experience is required.* (Candidates whose RCM experience was gained from hospitals will not be considered).
• Strong knowledge and experience in ICD-10-CM and ICD-10-PCS.
• Hands-on experience with DRG, POA, CC/MCC, and inpatient coding guidelines.
• Strong understanding of medical terminology and clinical documentation.
• Knowledge of official coding guidelines and AHA Coding Clinic guidance.
• Experience using automated encoder and abstracting systems.
• Strong analytical and attention-to-detail skills.
• Excellent English communication skills, both written and verbal.
• Must be comfortable working with computer-based coding and documentation systems.
• Must be able to consistently meet quality and productivity standards.

Education:

• Bachelor's degree in Medical Records, Allied Medical Field, or a related discipline is preferred.
• Equivalent relevant clinical or medical coding experience may also be considered.

Certification:

Coding certification may be required depending on client requirements. The following certifications are considered an advantage:

• AAPC: CPC, COC, CIC
• AHIMA: CCA, CCS-P, CCS

What We Offer

• Fully Remote Work Setup
• Opportunity to work with a Healthcare/BPO
• Competitive compensation package
• Professional growth and development opportunities
• Laptops will be provided by the company.
• HMO coverage is provided from Day 01. After 6 months, HMO coverage includes up to 3 dependents.
• SIGN ON BONUS = equivalent to 1 mo. salary

Benefits:

• Additional leave
• Health insurance
• Life insurance

Work Location: Remote