Position Summary
We are seeking experienced Inpatient Medical Coders to support a large federal healthcare program. This role is responsible for reviewing inpatient medical records, assigning accurate ICD-10-CM and ICD-10-PCS codes, and ensuring compliance with all applicable coding regulations, documentation standards, and reimbursement guidelines.
The ideal candidate will have strong inpatient coding experience, prior experience supporting Veterans Affairs (VA) healthcare facilities, and the ability to work independently in a remote environment while maintaining exceptional quality and productivity standards.
Minimum Qualifications
- Minimum of two (2) years of inpatient coding experience.
- Previous VA healthcare coding experience strongly preferred.
- Strong inpatient coding and consulting background.
- Active coding certification from AHIMA or AAPC.
Key Responsibilities
Inpatient Coding & Record Review
- Review and analyze inpatient medical records to identify all diagnoses and procedures affecting the admission.
- Assign accurate ICD-10-CM and ICD-10-PCS codes based on provider documentation.
- Maintain a minimum coding accuracy rate of 95%.
- Ensure all coding assignments comply with federal healthcare coding guidelines and industry standards.
- Code all applicable diagnoses, including conditions documented as probable, possible, or affecting patient treatment.
- Accurately sequence diagnoses and procedures according to coding regulations and reimbursement requirements.
- Utilize coding software and electronic health record systems to complete coding assignments.
Procedure Coding Expertise
Candidates must be proficient in coding inpatient procedures including, but not limited to:
- Alcohol and drug rehabilitation or detoxification services (acute care)
- Procedures requiring sedation or anesthesia
- Cardiac catheterizations and arteriography procedures
- Interventional radiology procedures
- PICC lines, central lines, and arterial catheter insertions
- Chest tube insertions
- Chemotherapy administration
- Dialysis and dialysis catheter procedures
- Electroconvulsive therapy (ECT)
- Extracorporeal Shock Wave Lithotripsy (ESWL)
- Excisional debridement procedures
- Intubation and mechanical ventilation
- Radiation therapy
- Thoracentesis and paracentesis procedures
- TPA administration, infusion, and instillation procedures
Compliance & Quality Assurance
- Comply with HIPAA, privacy, security, and confidentiality requirements.
- Adhere to AHIMA Standards of Ethical Coding and all applicable professional coding standards.
- Utilize coding references and resources to ensure accurate code assignment.
- Identify and escalate conflicting, ambiguous, or incomplete documentation through appropriate channels.
- Maintain compliance with annual privacy and security training requirements.
- Protect and securely handle all patient health information.
Required Knowledge & Skills
- Expert knowledge of ICD-10-CM, ICD-10-PCS, CPT, HCPCS, and Evaluation & Management guidelines.
- Strong understanding of inpatient coding methodologies and reimbursement principles.
- Knowledge of Correct Coding Initiative (CCI) bundling guidelines.
- Ability to accurately interpret complex clinical documentation.
- Knowledge of anatomy, physiology, pharmacology, pathology, disease processes, and medical terminology.
- Experience applying appropriate coding modifiers when required.
- Strong analytical and problem-solving skills.
- Excellent attention to detail and commitment to coding quality.
- Ability to work independently and manage workload effectively in a remote environment.
Required Education & Credentials
Candidates must possess one or more of the following active coding credentials:
AHIMA Certifications
- RHIA — Registered Health Information Administrator
- RHIT — Registered Health Information Technician
- CCS — Certified Coding Specialist
- CCS-P — Certified Coding Specialist – Physician-based
AAPC Certifications
- CPC — Certified Professional Coder
- CPC-H — Certified Professional Coder – Hospital
Additionally:
- Completion of an accredited coding, health information management, or health information technology program is required.
- Minimum of two years of inpatient and/or outpatient coding experience required.
Technical Requirements
- Experience working within electronic health record systems.
- Experience with Oracle Cerner and Federal EHR systems preferred.
- Proficiency with coding software, encoders, and healthcare information systems.
- Strong computer skills and ability to quickly learn new technologies.
- Dedicated home office or workspace free from distractions.
- Dual-monitor setup required.
- Reliable high-speed internet connection required.
- Must be highly tech-savvy and comfortable working remotely.
Schedule & Availability
- Work schedule to be determined based on project needs.
- Candidates should provide general availability and planned PTO when applying.
Work Environment
- Fully remote position.
- Long-term 12-month contract opportunity.
- Opportunity to support a nationally recognized federal healthcare program.
- Candidates must maintain productivity, quality standards, and confidentiality while working remotely.
