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Inpatient Coder - Coding and Documentation, Remote in FL OnlyFull Time

Company: Health First
Location: Rockledge
Posted on: November 24, 2022

Job Description:

* This position is a full time remote, work from home opportunity. You must reside within the state of Florida.


To be fully engaged in providing Quality/No Harm, Customer Experience, and Stewardship by providing timely, complete and accurate data collection for quality clinical analysis and revenue enhancement.


Quality/No Harm:

Maintain and observe patient confidentiality as outlined in the National Patient Safety Goals and HIPAA guidelines protecting the confidentiality of the health record at all times and refuse to access protected health information not required for coding-related activities.

Knowledge of the regulatory environment and legislation related to code assignment changes.

Ensures that all work areas and equipment, whether remote or on-site, are in safe and working condition.

Maintain a clean, safe, and organized work atmosphere.

Literacy and proficiency in computer technology and Health Information/Coding applications needed for departmental efficiency and job performance.

Solid proficiency in computer assisted coding work flow processes with accurate execution and efficiency.

Uphold regulatory compliance by consulting validated coding references for accurate code assignment and sequencing rules, i.e., ICD-9/ICD10 and CPT-4 Official Coding Guidelines, AMA Coding Clinic for ICD-9/ICD-10, AMA Coding Clinic for HCPCS, AMA CPT Assistant, National Correct Coding Initiative edits, National and Local Coverage Determinations, medical dictionary, pharmaceutical and drug references, and anatomy and physiology references, etc.

Validate accuracy of codes assigned by the Computer Assisted Coding tool, recognizing inappropriate application of clinical coding rules/guidelines making revisions to the codes assigned based upon expert subject knowledge and provider documentation.

Interpret clinical documentation to ensure codes reported are clearly and consistently supported by the health record.

Request clarification from provider when there is conflicting, incomplete, or ambiguous information in the health record regarding a significant reportable condition or procedure or other reportable data element.

Maintain coding accuracy as per departmental standards-approving, editing, and assigning ICD-9-CM and CPT-4 codes in the computer assisted coding application based on physician documentation in accordance to Coding and Compliance Guidelines.

Abstract pertinent information accurately and completely into the computer assisted coding application.

Abstract Present On Admission Indicator on inpatient medical records as per the ICD-9-CM Coding Guidelines related to this topic.

Verify documentation of patient status is indicated in the medical record.

Verify and revise according to documentation in the medical record of the proper discharge disposition.

Notification to medical records/registration personnel of any identified discrepancies of patient information in the medical record.

Knowledge of structure and content of the electronic health record displaying ability and competency to navigate the EHR accurately and efficiently for data quality collection and code assignment.

Attends monthly department meetings and bi-monthly coding roundtables.

Attends departmental educational opportunities offered related to the appropriate field of coding expertise.

Earn 8 CEU's yearly related to coding profession.

Review Coding Clinic for ICD-9 quarterly updates and complete coding clinic quizzes.

Customer Experience:

Excellent communication, problem solving and critical thinking skills.

Provide professional and courteous communication to customers, families, other associates, and leadership at all times.

Provide professional, precise, and complete communication with physician office/registration staff regarding documentation concerns related to post discharge queries as necessary to clarify documentation/coding related issues.

Respond and relay documentation/coding issues/concerns from and to Health First departments and physician's offices in a polite and considerate demeanor, utilizing the highest standard of customer services skills.

Demonstrate behavior that reflects integrity, shows a commitment to ethical and legal coding practices, and fosters trust in professional activities.

Always displays professionalism and respect; every person, every time.


Optimize the DRG of each inpatient medical record always following the official ICD Coding Guidelines for each case scenario.

Maintains productivity standards according to departmental guidelines.

Meets discharged not final coded (DNFC) departmental goals.

Responds timely to pre-bill edits received ensuring a prompt turn-around-time to assist in facilitating an efficient revenue cycle.

Analyze and reply to denial management issues presented identifying documentation concerns and validating accuracy and completeness in code assignment.

Provide departmental coding coverage by cooperating with occasional schedule revisions and overtime requests when staffing needs arise.

Accountable and dependable time and attendance record to ensure daily workflow and departmental productivity guidelines are met.

4 years inpatient coding experience with coding certification (AHIMA or AAPC)


Non-certified with 8 years inpatient coding experience


Successful completion of internal DRG inpatient coding assessment with passing score of at least 75%.

Keywords: Health First, Melbourne , Inpatient Coder - Coding and Documentation, Remote in FL OnlyFull Time, Other , Rockledge, Florida

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