Inpatient Coder/Abstractor - Health Information Management

Job Summary: The Inpatient Coder is responsible for accurately assigning diagnosis and procedure codes to inpatient discharges at the smaller McLeod Health facilities representing less complex medical/surgical encounters.

1. Keeps abreast of all new coding developments by attending any coding classes, reading articles on coding updates, and attending seminars when available.

2. Possess inpatient coding knowledge and experience necessary to accurately assign codes to determine correct principal diagnosis, identify and assign co-morbidities and complications, secondary diagnoses, present on admission indicator, discharge disposition, Hospital Acquired conditions, principal procedure and secondary procedures on all discharged inpatient records to arrive at the most appropriate DRG assignment.

3. Codes all Obstetrics, Newborn and Behavioral Health encounters at applicable facilities if assigned by Supervisor and/or Director.

4. Queries physicians appropriately when documentation is not clear in the medical record.

5. Must work closely with the Clinical Documentation Specialists to assure the most optimal DRG is assigned.

6. Maintains department specific productivity standards with a 95% accuracy rate.

7. Other duties as assigned.

Work Schedule: 80 hours bi-weekly

Requirements:
 Licenses and Certifications:
   AHIMA Registered Health Information Technician
 Memberships:
   Occupation Risk Assessment