The HIM Hospital Inpatient & Same Day Surgery Coding Analyst interprets provider documentation in the health record and assigns diagnostic and procedural codes for complex acute care services. This role applies ICD-10-CM/PCS, CPT, DRG, and APR-DRG coding expertise, performs audits, provides feedback, and delivers advanced training to clinical teams and physicians on coding best practices.
Essential responsibilities
- Review and analyze inpatient medical records for completeness, accuracy, and compliance for same day surgery, observation, and inpatient acute services.
- Perform advanced-level coding for inpatient hospital accounts, including charts with extended stays, multiple surgeries, and numerous consultations.
- Assign appropriate diagnosis and procedure codes using ICD-10-CM/PCS, CPT, and other coding systems.
- Ensure coded data accurately reflects severity of illness, risk of mortality, and quality of care.
- Query physicians and other clinical staff when clarification or documentation is needed.
- Validate DRG, APR-DRG, ambulatory assignments, and reimbursement calculations.
- Follow AHIMA Code of Ethics and Standards of Ethical Coding.
- Follow coding policies and procedures and report issues or discrepancies.
- Perform coding audits and provide feedback and education to coders and clinical staff.
- Participate in coding quality improvement initiatives and projects.
Requirements & Qualifications
Required qualifications
- High school diploma or GED.
- Coding certification from AHIMA or AAPC.
- Expert-level ability to understand and compliantly apply complex coding and billing requirements.
- Strong knowledge of medical terminology, medical acronyms, pharmacology, anatomy and physiology, ICD-10-CM/PCS, DRG, and APR-DRG classification systems.
- Ability to complete and pass an internal coding exam.
- Proficiency with coding software, electronic health records, and other health information systems.
- Excellent communication, interpersonal, and analytical skills.
- Ability to work independently and collaboratively in a fast-paced environment.
Preferred qualifications
- Associate degree or higher in health information management, health informatics, or a related field.
- Acute care facility coding experience with ICD-10-CM and ICD-10-PCS across multidisciplinary service lines.
- Experience with EPIC EHR and 3M 360 CAC using 3M automation tools.
Location
Colorado, US
Employment Type
Full-time
Experience Level
Senior
Remote work allowed
No
Posted
1 week ago
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