Job Description

Responsibilities

• Review inpatient medical records, physician documentation, diagnostic reports, and treatment records to assign accurate ICD-10-CM and ICD-10-PCS codes.
• Analyze complex inpatient encounters to ensure complete and accurate coding of diagnoses, procedures, complications, comorbidities, and severity of illness.
• Abstract and enter coded data into the electronic health record (EHR) and coding systems in accordance with established guidelines and timelines.
• Ensure compliance with official coding guidelines, regulatory requirements, organizational policies, and payer-specific standards.
• Review clinical documentation for completeness, accuracy, and specificity to support appropriate code assignment and reimbursement.
• Query physicians and other healthcare providers when clarification or additional documentation is required.
• Assign and validate Diagnosis-Related Groups (DRGs) to support accurate reimbursement and case classification.
• Collaborate with Clinical Documentation Improvement (CDI) specialists, physicians, case managers, and revenue cycle teams to optimize coding quality and documentation integrity.
• Conduct coding audits and participate in quality assurance activities to maintain coding accuracy and compliance.
• Identify coding trends, documentation deficiencies, and opportunities for process improvement.
• Support internal and external audits by providing coding rationale and required documentation.
• Monitor coding-related denials and work with relevant departments to resolve coding and documentation issues.
• Ensure appropriate capture of patient acuity, complications, comorbidities, and procedures to accurately reflect the patient’s clinical condition.
• Maintain productivity, quality, and turnaround time standards established by the organization.
• Stay current with updates to ICD-10-CM, ICD-10-PCS, DRG methodologies, coding regulations, and reimbursement guidelines.

Qualifications

• Bachelor’s degree in Health Information Management, Medical Records, Healthcare Administration, Nursing, Pharmacy, or a related healthcare field.
• Professional coding certification such as CPC (Certified Professional Coder), ICD-10-CM, CPT, and HCPCS