Inpatient Coder

This job description outlines the essential functions of the position, providing clarity on the role, its place in the organization, and the required skills and work expectations. Jobs evolve over time, and this description does not limit normal growth or change. Reasonable accommodations will be made for qualified individuals to perform the essential functions of the job.

About the Role

The Inpatient Coder is responsible for admissions, concurrent, and discharge coding; assembling medical records; and analyzing records to flag deficiencies. This role involves thoroughly reviewing all patient medical charts to ensure accuracy of information. The position does not involve direct patient care for individuals ages 18 and older, and age-specific experience or special training is not required.

Qualifications

• Minimum of a High School Diploma (Associate’s Degree preferred).
• Certified Coding Associate (CCA) or Certified Coding Specialist (CCS) certificates preferred.
• Minimum of one (1) year of experience in Long Term Acute Care Coding and Medical Records (preferred).
• Strong interpersonal skills.

Responsibilities

• Reviews and codes inpatient and/or outpatient medical information.
• Compiles statistics and prepares/maintains records and reports; finalizes attending physicians’ attestations and obtains signatures.
• Researches and locates missing data and records needed for coding and abstracting.
• Retrieves patient records for doctors and nurses for future diagnosis and treatment.
• Tracks medical records to document improvement or deterioration in patient condition.
• Processes admission and discharge paperwork.
• Serves as a liaison between providers and the billing office.
• Performs additional administrative duties as assigned by supervisor.

Work Demands and Environment

The role involves the following physical and environmental demands:

• Standing/Walking: 34-66% of work time.
• Sitting, Twisting, Lifting/Carrying, Pushing/Pulling, Climbing, Bending/Stooping: 1-33% of work time each.
• Using arm, leg, or back muscles frequently or for extended periods: 1-33% of work time each.
• Lifting Requirements: Individuals may be required to lift patients with or without assistance, with the following distribution:
  • 2-10 Pounds: 1-33%
  • 11-20 Pounds: 1-33%
  • 21-30 Pounds: 1-33%
  • 31-40 Pounds: 1-33%
  • 41-50 Pounds: 1-33%
  • 51 Pounds or More: 1-33%
• Working Environment: Potential exposure to:
  • Hot, cold, or wet surroundings (1-33%).
  • Outdoor conditions (1-33%).
  • Chemicals, radiation sources, communicable diseases, or hazardous waste materials (1-33% each).
  • Essential or adaptive equipment, hand tools, or vehicles (1-33% each).
  • Potential for cuts and bruises (1-33%).
• Exchange of Ideas:
  • Ability to express or exchange ideas: 67-100%.
  • Ability to understand communication of others (with or without adaptive devices): 67-100%.
  • Ability to perform secondary-level math and reading: 67-100%.

Workplace Behaviors

• Results Orientation: Meets objectives, completes daily tasks, and processes large volumes of work efficiently.
• Social Sensitivity: Builds positive relationships, demonstrates a helpful attitude, and maintains effective communication with peers, medical staff, patients, visitors, and families.
• Quality Outcomes: Meets and exceeds customer expectations, adheres to organizational and departmental standards, and maintains confidentiality. Participates in quality improvement programs as directed.
• Safe Working Environment:
  • Adheres to safety and legal requirements.
  • Reports accidents, injuries, unsafe equipment, or conditions immediately.
  • Complies with regulations (OSHA, Accreditation, etc.).
  • Attends safety-related training as required.
  • Accepts modified work assignments after physician release following an accident/injury.
  • Follows prescribed treatment after an accident/injury.
• Education: Participates in required in-service and educational programs.
• Attendance and Punctuality: Follows facility guidelines for attendance and punctuality.

Universal Precautions

Universal precautions will be observed to prevent contact with blood or other potentially infectious materials. All body fluids are considered potentially infectious, regardless of perceived status. This position is classified as Category II: Tasks typically involve no contact with moist body substances, non-intact skin, or mucous membranes, but may require performing unplanned Category I tasks. Appropriate protective measures are readily available.

Pay

$23/hour.