This is a remote, advanced position functioning under general supervision and utilizing independent decision making. -The Coder Inpatient II correctly assigns ICD diagnosis and procedure codes and MS-DRGs for inpatient hospital services at Hospital, an academic, Level I Trauma Center. -The Coder Inpatient II codes a variety of medical and surgical specialties such as Neurology, Oncology, Urology, Transplant, OB/Newborn, Ortho, Cardiology, and Critical Care which can include complex trauma and acutely ill patients. -Coders in this role communicate with care providers when necessary mainly via the electronic query process. -In order to ensure the most appropriate DRG assignment, coders partner with clinical documentation improvement specialists with the goal of obtaining the most complete and accurate medical record documentation. -The Coder Inpatient II will resolve problems and make decisions independently. -The coders in this position will apply all departmental coding quality guidelines and meet productivity standards, while maintaining a 95% overall accuracy rate. -The coder must understand that the hospital's strategic initiatives (financial, statistical and quality benchmarking) rely on the accuracy and integrity of all data coded by them. -Effective communication is vital to this position. -A high degree of ability to adapt to change and work as a team is extremely important to this role. -Other duties as assigned. -Accurately assigns DRG's to hospital inpatient accounts. -Accurately assigns diagnosis and procedure codes. -Abstracts required information from accounts accurately per facility guidelines. -Queries physicians when documentation is incomplete following facility guidelines and procedures. -Writes queries independently with minimal assistance from the coordinators. -Shows minimal need to query following reviews as documented in QA findings. -Assigns Present on Admission (POA) indicators accurately. -Maintains productivity (charts per hour) in accordance with facility expectations. -Assigns codes for all assigned acuities and procedures attaining the standard for the appropriate case mix average for this coding role. -Assigns codes for all assigned length of stays attaining the standard for the length of stay average for this coding role. -Maintains the standard productive percent Works the Combine/Uncombine process as assigned Codes mortality cases accurately and timely in accordance with hospital policy Codes Rehab cases for both facilities at admission and discharge Denials/Support Sends timely and thorough rebuttals for insurance denials when requested Participates in other projects as assigned.
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Career Level
Mid Level
Education Level
Associate degree