Inpatient Coder

Pay: $30.00 - $35.00 per hourLocation: 100% Remote workShift: Monday through Friday, 8:00 AM EST to 5:00 PM EST - some extended hours at month end close and occasionally when neededPosition Summary:The Inpatient Medical Coder at SRMC is responsible for accurately reviewing and assigning ICD-10-CM and ICD-10-PCS codes to patient records for inpatient encounters, ensuring that documentation supports correct MS-DRG/APR-DRG assignment, severity of illness, and risk of mortality. The coder ensures compliance with federal coding guidelines, hospital standards, and payer-specific requirements. The role is critical in supporting revenue integrity, clinical accuracy, and quality reporting for the hospital.Key Responsibilities:Medical Record Coding & Review:Assign ICD-10-CM diagnosis and ICD-10-PCS procedure codes to inpatient medical records using official guidelines and facility coding policies.Validate principal diagnosis, secondary diagnoses, and procedures to determine the appropriate MS-DRG/APR-DRG assignment.Apply POA indicators and flag Hospital Acquired Conditions (HACs) as applicable.Interpret complex clinical documentation from physicians and specialists across service lines.Abstract and enter coded data into the hospital’s EHR and encoder systems (e.g., 3M, Epic, or similar platforms).Clinical Documentation Integrity (CDI) and Query Process:Identify incomplete, conflicting, or unclear clinical documentation.Initiate compliant, non-leading queries to physicians when clarification is required for:o Diagnosis specificity (e.g., type of anemia, heart failure, sepsis)o Present-on-admission (POA) statuso Clinical validation when indicators do not support diagnosiso Procedure specificity or sequencingWork collaboratively with CDI teams, providers, and coding supervisors to resolve open queries and update codes accordingly.Maintain query logs and monitor physician response times per SRMC policy.Compliance & Reporting:Adhere to CMS, AHA Coding Clinic, AHIMA, and SRMC coding compliance policies.Participate in internal coding audits and SRMC reviews; respond to audit requests and implement corrective actions as necessary.Keep up to date with changes in coding regulations, guidelines, and payer requirements.Quality & Productivity:Maintain coding accuracy ≥95% and productivity benchmarks (2.5–3.0 charts/hour, adjusted for case mix).Consistently meet internal turnaround time for discharged-not-final-billed (DNFB) metrics.Contribute to lowering DNFB rates and supporting revenue cycle efficiency.Qualifications:Required Certification: CCS, RHIT, or RHIA (AHIMA-certified)Experience: Minimum 2 years of inpatient coding in a US Acute Care setting (teaching or community hospital)Strong knowledge of:o ICD-10-CM, ICD-10-PCSo DRG (MS-DRG, APR-DRG) assignment logico POA/HAC indicatorso Clinical documentation improvement processesProficiency in electronic health records and coding tools (3M, TruCode, Epic/Cerner)Familiarity with U.S. Virgin Islands Medicaid/Medicare and payer nuances is an added advantage.Working EnvironmentThis role may involve working with secure and confidential data, requiring adherence to strict data security and privacy standards. Some after-hours or weekend availability may be required during system maintenance, and month end operations.We are an Equal Opportunity Employer. All qualified applicants are considered for employment without regard to race, color, age, religion, sex, sexual orientation, gender identity, national origin, disability, protected veteran status, or any other characteristic protected by federal, state or local law.