Job Summary We are seeking an experienced and certified Medical Coder - Inpatient & Outpatient to join our Health Information Management/Revenue Cycle team. The Medical Coder is responsible for accurately reviewing and coding inpatient and outpatient hospital medical records in accordance with official coding guidelines, CMS requirements, payer regulations, and hospital policies. This position plays an essential role in ensuring coding accuracy, regulatory compliance, timely reimbursement, and the integrity of clinical and financial data. The successful candidate will demonstrate strong knowledge of hospital coding, medical terminology, anatomy and physiology, reimbursement methodologies, and regulatory requirements. Essential Duties and Responsibilities Review inpatient and outpatient medical records and accurately assign ICD-10-CM, ICD-10-PCS, CPT, and HCPCS codes based on assigned account type. Assign and validate appropriate MS-DRG/APR-DRG, APC, Present on Admission (POA), Severity of Illness (SOI), Risk of Mortality (ROM), and other applicable classifications. Apply Official Guidelines for Coding and Reporting, AHA Coding Clinic, CPT guidance, CMS requirements, payer policies, and organizational coding procedures. Review clinical documentation to ensure diagnoses and procedures are supported by the medical record. Abstract required clinical and administrative information accurately into the electronic health record and coding/encoder systems. Identify incomplete, conflicting, or unclear documentation and initiate compliant provider queries when clarification is necessary. Maintain established coding accuracy, productivity, turnaround-time, and quality standards. Identify coding or documentation issues that may affect reimbursement, compliance, quality reporting, or claim submission. Collaborate with Clinical Documentation Integrity (CDI), Health Information Management, Revenue Cycle, Patient Financial Services, Quality, Compliance, physicians, and other clinical departments. Review and resolve coding edits and assist with coding-related denials, audits, validation reviews, and payer inquiries. Participate in coding audits, education, performance improvement, and corrective-action initiatives. Maintain current knowledge of ICD-10-CM/PCS, CPT, HCPCS, CMS, Medicare, Medicaid, and other applicable coding and reimbursement requirements. Maintain required professional certification and complete applicable continuing education requirements. Protect patient confidentiality and comply with HIPAA and organizational privacy and security requirements. Perform other related duties as assigned. Minimum Qualifications High school diploma or GED required. Associate degree in Health Information Management (HIM), Health Information Technology (HIT), Medical Coding, or a related field preferred. Current nationally recognized medical coding certification required.

Acceptable certifications may include:

Certified Coding Specialist (CCS) Registered Health Information Technician (RHIT) Registered Health Information Administrator (RHIA) Certified Professional Coder (CPC) Certified Coding Specialist - Physician-Based (CCS-P) Certified Outpatient Coder (COC) Minimum of 3 years of hospital coding experience preferred for independent inpatient or combined inpatient/outpatient coding assignments. Strong knowledge of ICD-10-CM, CPT, HCPCS, medical terminology, anatomy, physiology, disease processes, and pharmacology. Candidates assigned inpatient coding responsibilities must demonstrate proficiency in ICD-10-PCS, MS-DRG/APR-DRG, POA, and UHDDS requirements . Knowledge of CMS, Medicare, Medicaid, payer requirements, and official coding guidelines. Ability to meet established coding accuracy and productivity standards. Strong analytical, organizational, problem-solving, and communication skills. Proficiency with electronic health records, coding encoders, and standard computer applications. Preferred Qualifications CCS, RHIT, or RHIA certification for inpatient coding. 4-5 or more years of recent acute-care hospital coding experience. Experience coding complex inpatient medical and surgical cases. Experience with high-acuity service lines such as ICU, cardiovascular, neurology/neurosurgery, orthopedics, trauma, behavioral health, or other specialty services. Experience with Epic, Cerner, Meditech, 3M/Solventum, Optum, or comparable EHR, encoder, or computer-assisted coding systems. Experience collaborating with Clinical Documentation Integrity (CDI) professionals and providers. Experience with coding audits, denials, payer reviews, and reimbursement validation. Demonstrated coding accuracy of approximately 95% or greater. Previous remote hospital coding experience, if applicable to the position. Certification Requirement Current coding certification is required for both full-time and part-time positions. CCS, RHIT, or RHIA certification is strongly preferred for candidates performing inpatient facility coding. CPC, CCS-P, or COC certification may be appropriate for outpatient or professional coding assignments. Candidates assigned inpatient coding responsibilities must also demonstrate proficiency in ICD-10-PCS and inpatient reimbursement methodologies.

Pay:

$30.00 - $35.00 per hour Expected hours: 37.5 per week

Benefits:

Dental insurance Health insurance Paid time off Tuition reimbursement Vision insurance

Work Location:

In person