Facility Inpatient Coder (Remote)

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What you will be doing in this role :

Working under the general direction of a coding supervisor, the Facility Inpatient Coder is responsible for the assignment of ICD-10-CM and ICD-10-PCS codes by reviewing all appropriate documentation in accordance with standard coding guidelines. Correctly identifies the principal diagnosis, comorbidities / complications, present on admission indicators, and determines sequencing of codes to calculate the most appropriate DRG representing the patient stay. Knowledge of both Medicare Severity Diagnosis Related Groups (MS-DRG) and All Patient Refined Diagnosis Related Groups (APR-DRG) is required. This position will require knowledge of appropriate capture of codes for statistical purposes such as Social Determinants of Health (SDOH), Hierarchical Conditions (HCC), and severity impacting conditions.

Abstracts data elements to satisfy statistical requests by the health system, medical staff, and enters all coded / abstracted information into the assigned system. Identifies opportunities for documentation improvement and seeks clarity by the physicians. Communicates collaboratively with the Clinical Documentation Integrity (CDI) team to align both clinical and coding approaches to ensure a complete coding profile. Ability to reference anatomy, physiology, and clinical practice to support code assignment and contribute to CDI discussions.

The position requires abstraction of coded data in a timely and accurate manner into the applicable system using the applications appropriate to the work assignment. This may include : EPIC (CSLink), EPIC HB, Solventum 360Encompass, Solventum Standalone Encoder, Select Coder, etc.

Translates medical records / health information including diagnoses, procedures and treatment and assigns standardized codes (International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM), International Classification of Diseases, Tenth Revision, and Procedure Coding System (ICD-10-PCS), for patients receiving services within the Cedars Sinai Health System and its affiliates. Primary duties include :

• Reviewing medical documentation / health information within various electronic medical / health system(s) and assigning applicable codes (ICD-10-CM, ICD-10-PCS) within productivity and quality standard for area(s) of assignment / specialty (Facility).
• Abstracting all required data elements for reporting and statistical capture.
• Resolving complex inpatient edits / alerts with consistent accuracy using current guidelines within area(s) of assignment / specialty.

Requirements :

High school diploma or GED required.

A minimum of 3 years’ work experience doing code assignment in a healthcare setting performing similar coding duties required.