Inpatient Coder

About the role

Come lead with us at Corporate At Houston Methodist, the Inpatient Coder position is responsible for ensuring diagnostic and procedure codes are assigned accurately to inpatient encounters based upon documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines. FLSA STATUS: Non-exempt.

Responsibilities

• People Essential Functions: Interacts and communicates effectively with members of the coding team and appropriate stakeholders; participates and provides good feedback during coding section meetings and coding education inservices; takes initiative to assist others and shares knowledge.
• Service Essential Functions: Responds promptly to internal and external customer requests; responds promptly and appropriately to requests to code or review coded accounts for accuracy; initiates queries with physicians to obtain or clarify diagnoses and/or procedures as appropriate, utilizing the established physician query process.
• Quality/Safety Essential Functions: Maintains and achieves highest standards of coding quality by assigning accurate ICD-10-CM/ICD-10-PCS codes using an electronic encoder application per hospital policy and regulatory guidelines; maintains department standards of abstracting quality by reviewing discharge disposition entered by nursing and correcting if necessary; assigns and enters physician identification number and procedure date correctly; reviews medical record documentation and abstracts data into encoder and EPIC/EHR to determine principal/final diagnosis, co-morbid conditions, complications, secondary conditions and procedures; utilizes all tools/resources for accuracy; complies with Standards of Ethical Coding per AHIMA and adheres to official guidelines.
• Finance Essential Functions: Utilizes time effectively; consistently codes and abstracts at departmental standards of productivity while ensuring accuracy; supports meeting organizational goal for Accounts Receivables associated with uncoded accounts; maintains coding timeframes within established departmental standards by ensuring all work items assigned to coding queues are processed timely.
• Growth/Innovation Essential Functions: Critically evaluates own performance, accepts constructive criticism, looks for ways to improve; displays initiative to improve relative to job function; contributes ideas to help improve quality of coding data and abstracting data.

Requirements

• Education: Associate’s degree or higher in a CAHIIM accredited program or additional two years of experience (in addition to the minimum experience requirements listed below) in lieu of degree.
• Experience: One year of relevant inpatient coding experience or successful completion of the Houston Methodist Coding Apprentice Program or Outpatient to Inpatient Coder Transition Program.
• Licenses and Certifications: Must have one of the following: RHIT - Certified Health Information Technician (AHIMA); RHIA - Registered Health Information Administrator (AHIMA); CCS - Certified Coding Specialist (AHIMA).
• Supplemental Requirements: Work attire – Business professional (uniform: No, scrubs: No, other department approved: No); On‑call – may be required during emergencies (disaster, severe weather events, etc.); Travel – may require travel within the Houston Metropolitan area and outside the Houston Metropolitan area.

Skills

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations.
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform essential functions, especially regarding activities impacting patient or employee safety or security.
• Ability to effectively communicate with patients, physicians, family members and co‑workers in a manner consistent with a customer service focus and application of positive language principles.
• Knowledge of coding classification systems, DRG and APC systems, official coding guidelines and coding compliance.
• Knowledge of an electronic medical record and imaging systems preferred.
• Working knowledge of medical terminology, anatomy and physiology.
• Proficiency with electronic encoder application preferred.
• Extensive PC knowledge – must be able to work effectively in common office software, coding software and abstracting systems.