Job Description
GENERAL SUMMARY:
As an Inpatient Complex Coder, you'll be the critical link between clinical documentation and accurate healthcare reimbursement. You'll review, analyze, and code diagnostic and procedural information from patient medical records with precision and expertise. Your work directly impacts reimbursement accuracy, supports vital medical research, and enables data-driven administrative decisions that enhance patient care. By ensuring compliance with coding guidelines, third-party policies, and accreditation standards, you'll help optimize reimbursement while maintaining the integrity of our healthcare data systems.
PRINCIPLE DUTIES AND RESPONSIBILITIES:
1. Conduct Comprehensive Medical Record Reviews
Thoroughly examine complete patient medical records—including histories, physicals, operative reports, pathology reports, therapy notes, nursing documentation, and discharge summaries—to identify all diagnostic and operative procedures and pertinent patient stay data. Verify documentation completeness and proactively request additional information to ensure full compliance with coding standards.
2. Assign Accurate Diagnostic and Procedural Codes
Apply established coding principles and guidelines to assign precise diagnostic and procedural codes using encoder software, ensuring every code reflects the clinical reality documented in the patient record.
3. Optimize MS-DRG Assignment and Sequencing
Identify the appropriate principal diagnosis and sequence all secondary diagnoses and procedures according to MS-DRG reimbursement system guidelines. Leverage your knowledge of optimization strategies to ensure accurate DRG assignment for all patients.
4. Ensure Medical Record Completeness
Verify the completeness of medical records within the electronic medical record system and promptly report any discrepancies to your supervisor to maintain data integrity.
5. Complete Discharge Abstracts
Compile comprehensive discharge abstracts by gathering pertinent patient stay data and integrating coded diagnostic and procedural information into our database systems.
6. Maintain Compliance and Professional Standards
Stay current with applicable Federal, State, and local laws and regulations. Uphold our Organizational Integrity Program and Standards of Conduct, demonstrating honest, ethical, and professional behavior in all coding activities.
7. Support Remote Coding Operations (if applicable)
If participating in our remote coding program, adhere to all Remote Coding Program policies and procedures.
8. Perform Additional Duties as Needed
Contribute to team success by completing other related duties as assigned.
Qualifications
EDUCATION/EXPERIENCE:
CERTIFICATIONS/LICENSURES REQUIRED:
Additional Information
This position is fully remote with flexible hours once trained.
Inpatient Complex Coder • Troy, Michigan, United States
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