Job Description

**Work remotely or on-site

Assigns appropriate ICD-10-CM codes and confirms appropriate, optimal DRG assignment for inpatient or outpatient accounts. Codes concurrently and retrospectively.

Abstracts clinical information from medical records. Assists with improvement in the overall quality of the coding function, coding team members, and clinical documentation to ensure compliance and optimum reimbursement. 


The primary purpose of the INPATIENT CODER is to:

1. Applies the appropriate diagnostic and procedural codes to individual patient health information for data retrieval, analysis, and claims processing.

2. Utilizes the appropriate clinical systems to identify opportunities for accurate and complete clinical documentation for measuring and reporting physician and hospital outcomes.

3. Queries providers when code assignments are not straightforward or documentation is inadequate, ambiguous, or unclear for coding purposes.

4. Provides education to providers, coding staff, and other departments as related to compliant documentation opportunities, code assignment and reimbursement.

5. Ensures weekly unbilled and monthly, quarterly, and year end goals are within 0.5-2.0 A/R days.  

6. Adheres to approved coding policies, guidelines, quality auditing, and Standards of Ethical Coding as set forth by corporate and AHIMA.

7. Functions as member of coding team performing work where needed.

8. Supports HIM Department by performing other tasks as requested.


Education: Will consider CCS incumbent or CCS, RHIA, RHIT.

Required: High School graduate or equivalent.

Preferred: Associates degree or bachelors in Health Information Management


To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Required: At least three to five year of inpatient/outpatient coding experience preferred. Must have extensive working knowledge of the coding classification systems, medical terminology, anatomy and physiology, and disease processes.

Skills, Knowledge, and Abilities:

1. Must possess expert knowledge of medical terminology, anatomy & physiology, and ICD-10-CM coding principles.

2. Must possess ability to assess a record and make independent, responsible decisions upholding policy and procedure.

3. Requires telephone communication, extensive reading, data entry, & prolonged sitting & bending to collect, review, & replace charts.

4. Proficient in business office skills.

5. Must possess ability to learn & perform all essential job functions accurately with minimal direct supervision within probationary period.


Certification Preferred: RHIT, RHIA, or CCS; if not credentialed, must receive within 6 months of date of hire (Primary Source Verification: AHIMA)

Application Instructions

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