Medical Coder – Inpatient

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Job Summary

The Medical Coder is responsible for ICD-10 coding of diagnoses and procedures of inpatient/outpatient discharged patient records.

Job Specific Responsibilities

Daily assignments may include but are not limited to:

• Apply diagnoses codes to in-patient, out-patient, and emergency services
• Maintain knowledge of current laws and regulations related to insurance, Medicare, Medicaid, and DRG coding, sequencing, and CPT coding
• Perform quality improvement reviews as assigned
• All other assigned duties related to Health Information Management

Inpatient Coder Duties:

• Review and analyze inpatient medical records to assign ICD-10-CM/PCS codes.
• Ensure completeness of the record to assign the accurate DRG (Diagnosis Related Group) assignment for reimbursement.
• Maintain knowledge of current coding guidelines, Coding Clinics and facility-specific coding policies.
• Collaborate with clinical documentation specialists as needed for unclear or inconsistent documentation requiring queries.
• Maintains knowledge of coding updates through provided or self- learning to ensure compliance with all changes.
• Maintain productivity and accuracy standards as defined by the department.

Outpatient Coder Duties:

• Review outpatient encounters including same-day surgery and observation.
• Assign appropriate ICD-10-CM, CPT, and HCPCS codes based on documentation.
• Ensure accurate coding for billing and regulatory compliance.
• Apply NCCI edits and modifier usage where applicable.
• Communicate with supervisor to clarify documentation when necessary.
• Meet department standards for productivity and accuracy.

Education and Experience

• High School Diploma or GED
• Completion of Medical Record Technology program
• + 2 years of experience in Health Information Management Coding

Required Licensures/Certifications/Registrations

• RHIT, RHIA, CCS, or coding certificate

Skills and Abilities

• Demonstrated skill in using 3M Encoder computer software for ICD-10-CM and CPT
• Demonstrated knowledge and understanding of diseases and their treatments and operative procedures
• Experience (or ability to learn) using Solventum 360 Encompass computer assisted coding.
• Experience (or ability to learn) using Cerner or Epic electronic health records system.
• Strong knowledge of medical terminology, anatomy and physiology.
• High attention to detail and coding accuracy.
• Ability to work independently and meet productivity deadlines.
• Excellent written and verbal communication skills.
• Ability to maintain patient confidentiality and comply with HIPAA and organizational policies.

Interaction with Other Departments and Other Relationships

This position will interact with medical staff and physicians throughout the hospital including Clinical Documentation Improvement (CDI) and Patient Financial Services (PFS).

Physical Capabilities

Position requires prolonged time periods of sitting at a desk, talking on a phone, and working on a computer. Essential hearing and near vision acuity required. Should be able to lift up to 10 pounds

Environmental/Working Conditions

Work area is well lighted, and subject to varying indoor temperature changes.

UMC Health System provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment on the basis of race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

*Request for accommodations in the hire process should be directed to UMC Human Resources.​*