Coder Inpatient

Essential Job Functions

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

Responsible for assigning 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 external regulatory and accreditation requirements as well as state and federal regulations. 

Extract pertinent data from the patient’s health record and determine appropriate coding for reports and billing documents. 

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

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

Maintain a 95% quality rating. 

Perform duties in compliance with the 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. 

• Minimum 5-7 years inpatient coding experience with recent coding experience
• Must have recent query writing experience - inpatient coders do write queries.
• Must have experience working with the CDI team. 
• Must be able to accept and respond to feedback; we have several prebilling review processes.
• Must be able to communicate effectively with email.
• Inpatient coding experience including level 1 Trauma and academic medical center is preferred. Must have experience at larger hospitals with at least 200 beds.
• RHIT or RHIA, and/or CCS
• Epic experience is preferred and must have experience using 3M 360 in the last two years.

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.