Inpatient Coding Specialist; Coder III - Fully Remote
Burlington, Middlesex County, Massachusetts, 01805, USA
Listed on 2025-12-13
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Healthcare
Medical Billing and Coding, Healthcare Administration, Medical Records
Job Title: Inpatient Coding Specialist (Coder III)
Hours: 40 hours per week. Monday through Friday.
Location: 100% remote.
Job Profile SummaryThis role focuses on activities related to revenue cycle operations such as billing, collections, and payment processing. In addition, the role performs Health Information Management duties, ensuring accuracy, maintenance, security, and confidentiality of patient health information, providing hands‑on support of daily business activities, and working under limited supervision while training lower level employees and analyzing non‑routine problems.
Job OverviewThis position reviews medical records to assure accurate specificity of diagnoses and procedures for inpatient admissions, effectively utilizes ICD‑10‑CM and PCS codes according to coding guidelines, communicates with providers and staff regarding missing information, manages deficiency creation in Epic, reviews denial reports, participates in audits, informs the supervisor of unusual/problematic accounts, attends meetings and education sessions, and performs related duties as assigned.
Job DescriptionMinimum Qualifications
- High school diploma or equivalent.
- Certified Coding Specialist (CCS), Certified Inpatient Coder (CIC), Registered Health Information Administrator (RHIA), or Registered Health Information Technician (RHIT).
- Three (3) years of ICD‑10‑CM and PCS coding experience.
- EMR experience.
- Associate’s degree.
- Five (5) years of inpatient ICD‑10‑CM and PCS coding experience within a teaching hospital or level one trauma center.
- Epic and CAC experience.
- Verifies and abstracts clinical and demographic data from the patient record.
- Performs chart audits prior to coding to ensure required documentation is complete and signed; queries appropriate providers or departments when deficiencies prevent the start of the coding process.
- Assigns accurately ICD‑10‑CM and ICD‑10‑PCS codes derived from medical record documentation for patient account.
- Reviews reports with leadership to identify discrepancies.
- Reviews audit lists regarding coding/billing changes, as well as denial reports.
- Identifies and evaluates coding issues, summarizes findings for leadership, makes recommendations for course of action, and works actively with physicians to initiate corrections and resolve discrepancies in coding and documentation.
- Ensures that all accounts are submitted accurately and in a timely manner.
- Works collaboratively with Compliance, Educators, and Auditors.
- Ensures that all medical records are coded and abstracted within 72 hours of patient discharge.
- Responsible to follow‑up on assigned discharges for final coding.
- Acts as a resource for answering coding questions from interdepartmental staff.
- Documents results of all special project work and provides recommendations relating to special projects.
- Attends meetings as necessary and participates on projects to ensure that all services are captured through codes.
- Maintains good relationship with providers and office personnel to facilitate good communication in coding queries.
- Promotes excellent customer service and identifies and communicates problems and/or opportunities to improve processes with management.
- Maintains collaborative, team relationships with peers and colleagues to effectively contribute to working group achievement of goals and to foster a positive work environment.
- Performs job intersections adhering to service principles with customer service focus of innovation, service excellence and teamwork to provide the highest quality care and service to patients, families, colleagues and community.
- Participates in coding audits of coding staff to maintain quality standards and offer feedback to management.
- Works closely with the DRG Validator to maintain high coding standards.
- Sedentary role requiring sitting most of the time, occasional standing & walking; mental requirements intense at times with many concurrent multi‑faceted projects.
- Manual dexterity using fine hand manipulation to operate computer keyboard.
- Ability to see computer screen and reports.
- Excellent organizational skills and…
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