Inpatient Medical Coder II ; Remote

Position Summary

Boston Medical Center (BMC) is more than a hospital. It is a network of support and care that touches the lives of hundreds of thousands of people in need each year. It is the largest and busiest provider of trauma and emergency services in New England. Emphasizing community-based care, BMC is committed to providing consistently excellent and accessible health services to all—and is the largest safety‑net hospital in New England.

The hospital is also the primary teaching affiliate of the nationally ranked Boston University School of Medicine (BUSM) and a founding partner of Boston Health Net – an integrated health‑care delivery system that includes many community health centers. Join BMC today and help us achieve our Vision 2030, a long‑term goal to make Boston the healthiest urban population in the world.

Inpatient Medical Coder II

Clinical Documentation

Full Time

Assigns appropriate codes to reflect all diagnoses and procedures extrapolated from physician and appropriate provider documentation during a patient encounter according to the most current coding methodologies, including ICD-10-CM and ICD-10-PCS resulting in appropriate reimbursement. Abstracts required data to input into the Medical Center's computerized database. Converts all patient visits and encounters into appropriate DRG (Diagnosis‑related group) MSDRG, APR DRG assignments in order to correctly submit the optimal reimbursement for each patient encounter coded.

• Reviews patient medical records and abstracts medical data that identifies all diagnoses and procedures. Codes diagnoses, procedures, and appropriate modifiers from the medical record documentation using ICD-10-CM/PCS, CPT4/HCPCS classification systems. Refers to a computerized encoding system, written coding aids and other reference materials to ensure accurate coding for billing.
• Sequences diagnoses, procedures and complications by following ICD-10-CM/PCS, CPT‑4, the Uniform Hospital Discharge Data Set (UHDDS); adheres to the Official Guidelines for Coding and Reporting, Coding Clinic guidelines and other regulatory guidelines as appropriate. Consults with the CDCI team to request appropriate physician or medical staff to clarify medical record information.
• Assigns grouper codes to each record according to patient type and financial class (DRG, ASC, APG, etc.). Enters coded/abstracted information in grouper, analyzes groupings, and assigns the appropriate grouper for accurate reimbursement. Data enters abstracted information into the Medical Center's computerized database.
• Assists the clinical documentation specialists in medical record documentation auditing as needed.
• Maintains accuracy rate of 95% or better.
• Maintains productivity standards set forth in Departmental Policies and procedures.
• Contacts Medical Records departments to track missing records so that all records can be billed.
• Maintains professional skills and knowledge of coding through attendance at in‑service programs, conferences, workshops and other educational programs and review of current literature. Assists in training new personnel in department coding procedures.
• Utilizes hospital’s behavioral standards as the basis for decision making and to facilitate the hospital’s goals and mission.
• Follows established Hospital infection control and safety procedures.
• Performs other duties as needed.

Level of knowledge equivalent to that ordinarily acquired through completion of an Associate's Degree in Health Information, Medical Records or similar program. An equivalent combination of education and experience, which provides proficiency in the areas of responsibility, may be substituted for the stated education and experience requirements.

3 years inpatient coding experience in a Level 1 Trauma, Teaching Facility.

• Preferred:
  Certified Coding Specialist
• Requires inpatient CCS, RHIT or RHIA credentials from AHIMA
• CCS coding credential requires inpatient coding experience before taking exam; RHIT and RHIA must have associate’s and bachelor’s degree respectively before taking exam.