Accurately review and code medical records to identify Hierarchical Condition Categories (HCCs) and other risk-adjusted codes in compliance with CMS guidelines. Perform chart reviews for documentation completeness and ensure all applicable codes are captured. Collaborate with providers to ensure proper documentation supports accurate coding. Monitor and adhere to compliance standards, including HIPAA regulations and organizational policies.

The Inpatient Coder position is responsible for ensuring diagnostic and procedure codes are assigned accurately to inpatient encounters based upon documentation within the electronic medical record while maintaining compliance with established rules and regulatory guidelines. You will interact and communicate effectively with members of the coding team and the appropriate stakeholders, and respond promptly to internal and external customer requests.

Under direct supervision, accurately codes hospital inpatient accounts for the purpose of appropriate reimbursement, research, statistics and compliance to federal and state regulations in accordance with established ICD-10-CM/PCS coding classification systems. The coder serves as a clinical coding subject matter expert, and utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed. They also analyze, code and abstract complex inpatient cases such as trauma, rehab, neurology, critical care, etc. utilizing the ICD-10-CM and ICD-10-PCS nomenclature to ensure accurate APR-DRG/SOI/ROM and POA assignment.

The Outpatient Coder II reflects the mission, vision, and values of NM, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines and all other regulatory and accreditation standards. Follows ICD-10-CM Official Guidelines for Coding and Reporting, Coding Clinics, and interprets ICD-10-CM coding conventions. Meets established minimum coding productivity per departmental protocol and guidelines.