Senior Certified Coding Associate

Job Title: Inpatient Coder

Type: Full Time

Location: Remote

Position Summary:

The Inpatient Medical Coder at SRMC is responsible for accurately reviewing and assigning ICD-10-CM and ICD-10-PCS codes to patient records for inpatient encounters, ensuring that documentation supports correct MS-DRG/APR-DRG assignment, severity of illness, and risk of mortality. The coder ensures compliance with federal coding guidelines, hospital standards, and payer-specific requirements. The role is critical in supporting revenue integrity, clinical accuracy, and quality reporting for the hospital.

Key Responsibilities:

Medical Record Coding & Review:

• Assign ICD-10-CM diagnosis and ICD-10-PCS procedure codes to inpatient medical records using official guidelines and facility coding policies.
• Validate principal diagnosis, secondary diagnoses, and procedures to determine the appropriate MS-DRG/APR-DRG assignment.
• Apply POA indicators and flag Hospital Acquired Conditions (HACs) as applicable.
• Interpret complex clinical documentation from physicians and specialists across service lines.
• Abstract and enter coded data into the hospital’s EHR and encoder systems (e.g., 3M, Epic, or similar platforms).

Clinical Documentation Integrity (CDI) and Query Process:

• Identify incomplete, conflicting, or unclear clinical documentation.
• Initiate compliant, non-leading queries to physicians when clarification is required for:
• Diagnosis specificity (e.g., type of anemia, heart failure, sepsis)
• Present-on-admission (POA) status
• Clinical validation when indicators do not support diagnosis
• Procedure specificity or sequencing
• Work collaboratively with CDI teams, providers, and coding supervisors to resolve open queries and update codes accordingly.
• Maintain query logs and monitor physician response times per SRMC policy.

Compliance & Reporting:

• Adhere to CMS, AHA Coding Clinic, AHIMA, and SRMC coding compliance policies.
• Participate in internal coding audits and SRMC reviews; respond to audit requests and implement corrective actions as necessary.
• Keep up to date with changes in coding regulations, guidelines, and payer requirements.

Quality & Productivity:

• Maintain coding accuracy ≥95% and productivity benchmarks (2.5–3.0 charts/hour, adjusted for case mix).
• Consistently meet internal turnaround time for discharged-not-final-billed (DNFB) metrics.
• Contribute to lowering DNFB rates and supporting revenue cycle efficiency.

Qualifications:

• Required Certification: CCS, RHIT, or RHIA (AHIMA-certified)
• Experience: Minimum 2 years of inpatient coding in a US Acute Care setting (teaching or community hospital)
• Strong knowledge of:
• ICD-10-CM, ICD-10-PCS
• DRG (MS-DRG, APR-DRG) assignment logic
• POA/HAC indicators
• Clinical documentation improvement processes
• Proficiency in electronic health records and coding tools (3M, TruCode, Epic/Cerner)
• Familiarity with U.S. Virgin Islands Medicaid/Medicare and payer nuances is an added advantage.