Description

The Senior Inpatient Coder is responsible for accurately assigning diagnosis and procedure codes to inpatient discharges at the larger McLeod Health facilities representing more complex medical/surgical encounters.

1. Maintains a professional image and exhibits excellent customer relations to patients, visitors, physicians, and co-workers in accordance with our Service Excellence Standards and Core Values. 
2. Maintains credentials as RHIA, RHIT or CCS with AHIMA is required. 
3. Keeps abreast of all new coding developments by attending any coding classes, reading articles on coding updates, and attending seminars when available.
4. Possess inpatient coding knowledge and experience necessary to accurately assign codes to determine correct principal diagnosis, identify and assign co-morbidities and complications, secondary diagnoses, present on admission indicator, discharge disposition, Hospital Acquired conditions, principal procedure, and secondary procedures on all discharged inpatient records to arrive at the most appropriate DRG assignment.  
5. Understands coding guidelines to accurately apply coding principles to encounters with longer lengths of stay, complex medical diagnoses and extensive surgical procedures.  This includes cardiac, neurosurgery, orthopedic, pediatric, trauma, and vascular.
6. Queries physicians appropriately when documentation is not clear in the medical record.
7. Works closely with the Clinical Documentation Specialists to assure the most optimal DRG is assigned.
8. Maintains department specific productivity standards with a 95% accuracy rate.
9. Respect patient confidentiality at all times.
10. Performs other duties as assigned.

Requirements

Qualifications/Education/Training:

1 to 2 years of inpatient coding in an acute care hospital setting preferred

Licenses and/or Certifications:

High School Diploma or equivalent preferred, Associate Degree preferred, RHIT, RHIA, or CCS certification required