IP Coder

Job Description

The IP Coding Specialist III is an advanced-level Inpatient Coding Specialist responsible for accurately reviewing, analyzing, and coding inpatient medical records. This position applies current ICD-10-CM/PCS coding guidelines, Official Coding Guidelines, and regulatory requirements to ensure accurate assignment of diagnoses, procedures, DRGs, CC/MCCs, POA indicators, and other critical clinical and coding data.

As a senior-level inpatient medical coder and coding subject matter expert, the IP Coding Specialist III is responsible for complex coding assignments based on education, training, certification, and extensive acute academic hospital coding experience. This role supports accurate clinical documentation, reimbursement, compliance, data quality, and severity-of-illness and risk-of-mortality reporting.

Earnings

$36-46 hourly

Duties

• Perform concurrent and retrospective inpatient coding of acute-care hospital medical records using ICD-10-CM and ICD-10-PCS.
• Apply current Official Coding Guidelines, coding conventions, regulatory requirements, and organizational policies to ensure accurate and compliant coding.
• Accurately identify and assign: Admit Diagnosis, Principal Diagnosis, Principal Procedure, Secondary Diagnoses, Complications and Comorbidities (CCs), Major Complications and Comorbidities (MCCs), Present on Admission (POA) indicators, Diagnosis-Related Groups (DRGs), Severity of Illness (SOI), Risk of Mortality (ROM)
• Abstract required inpatient data elements, including discharge disposition, procedure dates, attending and other physicians, and other designated clinical and administrative information.
• Review clinical documentation to identify missing, incomplete, conflicting, or unclear information.
• Recognize when a physician query is appropriate and route queries according to established guidelines and procedures.
• Complete final coding after receiving appropriate physician clarification or additional documentation.
• Maintain established UTSW/HIM coding quality standards and ensure coding accuracy and compliance.
• Meet established coding productivity standards while maintaining a high level of accuracy.
• Serve as a coding subject matter expert and mentor/train team members on designated coding service lines as requested.
• Maintain expert knowledge of inpatient coding guidelines, ICD-10-CM/PCS, DRG assignment, clinical documentation requirements, and coding compliance practices.
• Perform other duties and responsibilities as assigned.

Requirements

• One of the following professional credentials is required: RHIA, RHIT, CCS, CIC

Preferred Technical Skills

• Experience with Epic Electronic Medical Record (EMR/EHR)
• Knowledge of 3M 360
• Strong knowledge of ICD-10-CM/PCS inpatient coding
• DRG and reimbursement methodology knowledge
• Clinical documentation review and physician query experience
• Strong computer and data abstraction skills