Inpatient Medical Coder (Remote)

Position Summary

Our client is seeking an experienced Inpatient Medical Coder to join our Health Information Management (HIM) team. This role is responsible for accurately coding and abstracting diagnoses, procedures, and clinical information from inpatient medical records while ensuring compliance with all applicable coding guidelines, regulatory requirements, and organizational productivity standards.

The ideal candidate will have extensive experience with ICD-10-CM/PCS coding, MS-DRG and APR-DRG reimbursement methodologies, and complex acute-care hospital cases. This position requires exceptional attention to detail, strong analytical skills, and the ability to collaborate with Clinical Documentation Improvement (CDI) and HIM professionals to support accurate reimbursement and quality reporting.

Key Responsibilities

• Accurately review, code, and abstract inpatient medical records using ICD-10-CM/PCS coding conventions and guidelines.
• Apply ICD-10-CM/PCS Official Guidelines for Coding and Reporting, AHA Coding Clinic guidance, CMS regulations, and other applicable coding standards.
• Assign principal and secondary diagnoses and procedures according to Uniform Hospital Discharge Data Set (UHDDS) definitions and regulatory requirements.
• Utilize expertise in MS-DRG and APR-DRG methodologies to ensure appropriate reimbursement and coding accuracy.
• Assign and validate Present on Admission (POA) indicators.
• Identify and report Hospital-Acquired Conditions (HACs) supported by provider documentation and quality reporting requirements.
• Verify discharge disposition and patient data to ensure coding compliance.
• Create compliant physician queries following Guidelines for Achieving a Compliant Query Practice (2019 Update) to clarify conflicting, incomplete, or ambiguous documentation.
• Extract and enter required coding and abstracting information into encoder and abstracting systems.
• Review and resolve pre-bill edits, coding errors, and missing documentation elements.
• Partner with HIM staff and Clinical Documentation Improvement Specialists (CDIS) to support complete and accurate clinical documentation.
• Utilize coding software, electronic medical record (EMR) systems, and HIM applications to meet billing timeliness and DNFB goals.
• Maintain coding accuracy and productivity standards.
• Participate in continuing education activities, webinars, and workshops to maintain coding knowledge and required CEUs.

Minimum Qualifications

Required

• Minimum 5 years of inpatient coding experience using ICD-10-CM/PCS.
• Strong working knowledge of MS-DRG and APR-DRG reimbursement methodologies.
• Experience meeting established coding productivity and accuracy standards.
• Ability to successfully complete a pre-employment coding proficiency assessment.

Preferred

• Completion of an AHIMA-accredited program with one or more professional credentials such as:
  • CCS
  • RHIA
  • RHIT
• Associate degree or higher in Health Information Management or a related discipline.
• Experience working within a large acute-care hospital system (500+ beds).
• Familiarity with Epic EMR, 3M 360 Encompass, and other coding/abstracting systems.
  
  
  
  

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