Inpatient/Outpatient Coder
Core
Review inpatient and outpatient medical records to translate clinical documentation into accurate, compliant diagnosis and procedure codes for a large healthcare network.
Role type
Inpatient/Outpatient Medical Coder
Builds
Accurate coding data for billing, quality assurance, and healthcare reimbursement processes
Domain
Healthcare / Medical Coding
Required skills
ICD-10-CM, ICD-10-PCS, CPT, HCPCS Level II, coding guidelines, electronic health records, encoder tools, CPRS, VistA
Preferred skills
None stated
Responsibilities
Review inpatient and outpatient health records to identify reportable diagnoses, procedures, services, conditions, and required data elements; Assign and sequence ICD-10-CM, ICD-10-PCS, CPT, and HCPCS Level II codes in accordance with applicable coding guidelines; Code outpatient clinic, urgent-care, radiology, laboratory, ancillary, and ambulatory surgical services as assigned; Code inpatient episodes, including principal and secondary diagnoses, procedures, present-on-admission indicators, and DRG-related information; Complete required inpatient record transition types and follow established procedures for opening, correcting, and retransmitting records; Apply current coding guidance, Coding Clinic direction, CPT instructions, Correct Coding Initiative bundling rules, modifiers, and facility-specific protocols; Evaluate documentation to determine whether assigned codes are adequately supported and identify missing, conflicting, incomplete, duplicate, or erroneous information; Abstract and accurately enter or validate required data within CPRS, VistA, approved encoder systems, and other authorized applications; Re-review coded encounters during pre-bill processes or following denials, making supported corrections and providing coding justification when necessary; Maintain a minimum coding accuracy of 95% while meeting established turnaround, quality, and delivery requirements.