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Coder Inpatient

Omega Healthcare Management Services

Office

Boca Raton, FL, United States

Full Time

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Scope:

Seeking an experienced acute care inpatient coder with a minimum of 3 years of coding experience in a large acute care setting of at least 700 beds.  This role will code medical and surgical cases for multi specialties to include but not limited to cardiothoracic, cardiology, neurosurgery, neurology, vascular, orthopedics, oncology, pulmonary, infectious disease, neonatal, OB/GYN, general medicine and general surgery.  Complicated cases and long length of stays are common. Must have experience working with CDI.  Must be able to provide timely response to messages and have good written and verbal communication skills. Must have either a RHIA, RHIT or CCS certification. Experience with Cerner is required.  Experience with a CAC is required and experience with Optum eCAC is preferred. Productivity expectation is 1.5 charts per hour.  Quality expectation is a minimum of 95% accuracy.  Schedule is 8 hours a day M-F between the hours of 5am and 9pm EST.  Must be available during regular business hours (8a-5p EST) the first week for training. 

Summary/Objective 
Under limited supervision the Coder Inpatient reviews medical records and performs coding on all diagnoses, procedures, and  DRG.  The Coder Inpatient uses the most accurate codes for reimbursement purposes, research, epidemiology, statistical analysis outcomes, financial and strategic planning, evaluation of quality of care, and communication to support the patient’s treatment.  The Coder Inpatient will be charged with maintaining the confidentiality of patient records and procedures. 

 

Essential Job Functions 

Responsible for abstracting, coding, sequencing and interpreting the clinical information from inpatient, outpatient, emergency department, pro fee and clinical medical records. 

Responsible for the assignment of correct principal diagnoses, secondary diagnoses and principal procedure and secondary procedure codes with attention to accurate sequencing. 

Utilizes technical coding principals and DRG/APC reimbursement expertise to assign appropriate codes. 

Abstracts and codes pertinent medical data into multiple software programs and/or encoders.  Follows official coding guidelines to review and analyze health records. 

Maintains compliance with both external regulatory and accreditation requirements, and with State and Federal regulations. 

Extracts pertinent data from the patient’s health record, and determines appropriate coding for reports and billing documents. 

Identifies codes for reporting medical services, procedures performed by physicians.  Enters codes into various computer systems dependent upon the various clients. 

Track and document productivity in specified systems, maintain productivity levels as defined by the client. 

Maintain 95% quality rating 

Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance. 

 

 

Key Success Indicators/Attributes 

Ability to prioritize and multi-task in a fast-paced, changing environment. 

Demonstrate ability to work in all work types and specialties. 

Demonstrate ability to self-motivate, set goals, and meet deadlines. 

Demonstrate leadership, mentoring, and interpersonal skills. 

Demonstrate excellent presentation, verbal and written communication skills. 

Ability to develop and maintain relationships with key business partners by building personal credibility and trust. 

Maintain courteous and professional working relationships with employees at all levels of the organization. 

Demonstrate excellent analytical, critical thinking and problem solving skills. 

Skill in operating a personal computer and utilizing a variety of software applications. 

Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes. 

Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation. 

 

Supervisory Responsibility 

No 

 

Work Environment 

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones. 

 

 

Physical Demands 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. 

 

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear.  The employee must occasionally lift or move up to 25 pounds.  Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus. 

 

Position Type/Expected Hours of Work 

This is a full-time position.  Days and hours of work are generally Monday through Friday,.  This position occasionally requires long hours and weekend work. 

 

 

 

Required Education and Experience 

Successful completion of an AAPC or AHIMA-approved Coding Certificate Program and a minimum of two to four years of current production coding experience in both acute care and profee.   

 

Preferred Education and Experience 

N/A 

 

Additional Eligibility Qualifications 

Must have the following certificates and/or licenses:  RHIA, RHIT, or CCS.

 

Security Access Requirements 

In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega systems set forth in the “Standard Field Employee” profile.   

 

 

AAP/EEO Statement 

Omega is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, gender identity, disability status or protected veteran status. 

 

Other Duties 

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.  Duties, responsibilities and activities may change at any time with or without notice.  Employee may perform other duties as assigned. 

 

Qualifications for Internal Candidates  
  1. Minium of 3 years of IP coding experience in at least a 700 bed acute care facility
  2. Able to code medical and surgical cases for multiple specialties
  3. Comfortable coding complicated and long length of stay cases
  4. Experience with CDI DRG reconciliation
  5. Have a RHIA, RHIT or CCS certification
  6. Experience with Cerner
  7. Experience with a CAC, preferably Optum eCAC
  8. Able to work 8 hours a day M-F between the hours of 5am and 9pm EST
  9. Able to train the first week between 8am and 5pm EST
  10. Able to achieve production of 1.5 CPH after 4 weeks of ramp up and maintain afterwards
  11. Able to maintain 95% accuracy
  12. Good verbal and written communication skills

Scope:

Seeking an experienced acute care inpatient coder with a minimum of 3 years of coding experience in a large acute care setting of at least 700 beds.  This role will code medical and surgical cases for multi specialties to include but not limited to cardiothoracic, cardiology, neurosurgery, neurology, vascular, orthopedics, oncology, pulmonary, infectious disease, neonatal, OB/GYN, general medicine and general surgery.  Complicated cases and long length of stays are common. Must have experience working with CDI.  Must be able to provide timely response to messages and have good written and verbal communication skills. Must have either a RHIA, RHIT or CCS certification. Experience with Cerner is required.  Experience with a CAC is required and experience with Optum eCAC is preferred. Productivity expectation is 1.5 charts per hour.  Quality expectation is a minimum of 95% accuracy.  Schedule is 8 hours a day M-F between the hours of 5am and 9pm EST.  Must be available during regular business hours (8a-5p EST) the first week for training. 

Summary/Objective 
Under limited supervision the Coder Inpatient reviews medical records and performs coding on all diagnoses, procedures, and  DRG.  The Coder Inpatient uses the most accurate codes for reimbursement purposes, research, epidemiology, statistical analysis outcomes, financial and strategic planning, evaluation of quality of care, and communication to support the patient’s treatment.  The Coder Inpatient will be charged with maintaining the confidentiality of patient records and procedures. 

 

Essential Job Functions 

Responsible for abstracting, coding, sequencing and interpreting the clinical information from inpatient, outpatient, emergency department, pro fee and clinical medical records. 

Responsible for the assignment of correct principal diagnoses, secondary diagnoses and principal procedure and secondary procedure codes with attention to accurate sequencing. 

Utilizes technical coding principals and DRG/APC reimbursement expertise to assign appropriate codes. 

Abstracts and codes pertinent medical data into multiple software programs and/or encoders.  Follows official coding guidelines to review and analyze health records. 

Maintains compliance with both external regulatory and accreditation requirements, and with State and Federal regulations. 

Extracts pertinent data from the patient’s health record, and determines appropriate coding for reports and billing documents. 

Identifies codes for reporting medical services, procedures performed by physicians.  Enters codes into various computer systems dependent upon the various clients. 

Track and document productivity in specified systems, maintain productivity levels as defined by the client. 

Maintain 95% quality rating 

Perform duties in compliance with Company’s policies and procedures, including but not limited to those related to HIPAA and compliance. 

 

 

Key Success Indicators/Attributes 

Ability to prioritize and multi-task in a fast-paced, changing environment. 

Demonstrate ability to work in all work types and specialties. 

Demonstrate ability to self-motivate, set goals, and meet deadlines. 

Demonstrate leadership, mentoring, and interpersonal skills. 

Demonstrate excellent presentation, verbal and written communication skills. 

Ability to develop and maintain relationships with key business partners by building personal credibility and trust. 

Maintain courteous and professional working relationships with employees at all levels of the organization. 

Demonstrate excellent analytical, critical thinking and problem solving skills. 

Skill in operating a personal computer and utilizing a variety of software applications. 

Knowledge of coding convention and rules established by the AHIMA, American Medical Association (AMA), the American Hospital Association (AHA) and the Center for Medicare and Medicaid (CMS), for assignment of diagnostic and surgical procedural codes. 

Knowledge of JCAHO, coding compliance and HIPAA HITECH standards affecting medical records and the impact on reimbursement and accreditation. 

 

Supervisory Responsibility 

No 

 

Work Environment 

This job operates in a remote home office environment. This role routinely uses standard office equipment such as computers and phones. 

 

 

Physical Demands 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. 

 

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; and talk or hear.  The employee must occasionally lift or move up to 25 pounds.  Specific vision abilities required by the job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus. 

 

Position Type/Expected Hours of Work 

This is a full-time position.  Days and hours of work are generally Monday through Friday,.  This position occasionally requires long hours and weekend work. 

 

 

 

Required Education and Experience 

Successful completion of an AAPC or AHIMA-approved Coding Certificate Program and a minimum of two to four years of current production coding experience in both acute care and profee.   

 

Preferred Education and Experience 

N/A 

 

Additional Eligibility Qualifications 

Must have the following certificates and/or licenses:  RHIA, RHIT, or CCS.

 

Security Access Requirements 

In addition to the specific security access required by the employee’s client engagement, the employee will have access to the Omega systems set forth in the “Standard Field Employee” profile.   

 

 

AAP/EEO Statement 

Omega is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to race, religion, color, age, sex, national origin, sexual orientation, gender identity, disability status or protected veteran status. 

 

Other Duties 

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.  Duties, responsibilities and activities may change at any time with or without notice.  Employee may perform other duties as assigned. 

 

Qualifications for Internal Candidates  
  1. Minium of 3 years of IP coding experience in at least a 700 bed acute care facility
  2. Able to code medical and surgical cases for multiple specialties
  3. Comfortable coding complicated and long length of stay cases
  4. Experience with CDI DRG reconciliation
  5. Have a RHIA, RHIT or CCS certification
  6. Experience with Cerner
  7. Experience with a CAC, preferably Optum eCAC
  8. Able to work 8 hours a day M-F between the hours of 5am and 9pm EST
  9. Able to train the first week between 8am and 5pm EST
  10. Able to achieve production of 1.5 CPH after 4 weeks of ramp up and maintain afterwards
  11. Able to maintain 95% accuracy
  12. Good verbal and written communication skills

Founded in 2003, Omega Healthcare Management Services™ (Omega Healthcare) empowers healthcare organizations to deliver exceptional care while enhancing financial performance. We help clients increase revenues, decrease costs, and improve the overall patient-provider-payer experience through our comprehensive portfolio of technology and clinically enabled solutions. Omega Healthcare has 30,000 employees across 14 delivery centers in the United States, India, Colombia, and the Philippines. For more information, visit www.omegahms.com

Coder Inpatient

Office

Boca Raton, FL, United States

Full Time

August 14, 2025

company logo

Omega Healthcare Management Services

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