Certified Inpatient Coder (45863)

Under general supervision of the HIM Director, the Certified Inpatient Coder is responsible for reviewing inpatient medical records and accurately assigning ICD-10-CM diagnosis codes, ICD-10-PCS procedure codes, and MS-DRGs in accordance with official coding guidelines, federal regulations, and Tribal 638 facility policies. Upholds the principles of WIHCC’s Vision, Mission, and Value Statements. Maintains confidentiality of all privileged information at all times.

This list of duties and responsibilities is illustrative only of the tasks performed by this position and is not all-inclusive.

Essential Duties & Responsibilities:

• Maintains regular attendance and punctuality.
• Review inpatient medical records to identify all diagnoses and procedures relevant to each patient encounter.
• Assign ICD-10-CM and ICD-10-PCS codes according to official coding guidelines.
• Determine and assign the appropriate MS-DRG.
• Ensure coding reflects the highest level of specificity supported by documentation.
• Apply coding guidelines established by CMS, American Hospital Association, AHIMA, and Tribal/IHS coding policies.
• Analyzes, abstracts, codes, and processes the Medical and/or the Electronic Health Record (EHR) to ensure proper assignment of codes; CPT, ICD-10, and HCPCS in accordance with coding guidelines.
• Identify missing or conflicting documentation and initiate provider queries when necessary.
• Analyzes and retrieves data for research, diagnostic, and/or teaching purposes.
• Participate in coding audits and quality improvement activities.
• Assist in resolving coding edits and claim rejections related to coding.
• Maintains strict confidential policies complying with HIPAA and WIHCC policies due to the sensitive nature of patient information.
• Maintains current training of new and updated codes per coding guidelines.
• Completes continued annual education as required to maintain coding certification.
• Reviews and completes Coding Que and error reports.
• Enquires and obtains additional information from providers and staff to accurately code services rendered.
• Corrects coding mistakes.
• Compiles and reports coding and productivity reports on a weekly basis for reporting measures
• Upholds all principles of confidentiality and patient care to the fullest extent.
• Adheres to all professional and ethical behavior standards of the healthcare industry.
• Adheres to WIHCCs Personnel Policies and Procedures, departmental policies, rules, and regulations.
• Interacts in an honest, trustworthy and dependable manner with patients, employees, visitors, and vendors.
• Possesses cultural awareness and sensitivity.
• Maintains compliance with all Human Resources requirements.
• Performs other duties as assigned.

Minimum Qualifications:

High school diploma or GED required. Must have current certification with AAPC or AHIMA. (CIC, CCS). Three years progressive experience coding in inpatient setting. Bilingual skills in English and Navajo language preferred. Must maintain a valid unrestricted and insurable driver’s license. Must successfully pass a background investigation and maintain suitable requirements for a Child Care position. This position is considered as a Child Care position, which requires a satisfactory background check investigation and is subject to the requirements of the Indian Child Protection and Family Violence Prevention Act, as amended (henceforth referred as the ICPFVP Act).

Knowledge, Skills, Ability

• Knowledge of standards of medical records for meeting accrediting agency requirements.
• Knowledge of Medical Terminology and Anatomy & Physiology.
• Knowledge of ICD-10, CPT, and HCPCS
• Knowledge of MS-DRG methodology.
• Knowledge of strong work ethics in the workplace.
• Knowledge of basic application of confidentiality.
• Knowledge of basic computer skills, e.g. Outlook, Word, Excel, PowerPoint.
• Ability to analyze and retrieve data for research, diagnostic, and/or teaching purposes.
• Ability to abstract code from patient encounter forms, PCC’s or EHR.
• Ability to maintain and adhere to confidentiality of medical information and guidelines in accordance with the Privacy Act, HIPAA, HITECH, AAAHC, EMTALA and OSHA rules and regulations.
• Ability to be dependable in attendance and job performance.
• Ability to meet attendance, overtime (if necessary), and other reliability requirements of the job.
• Ability to accept and learn from feedback.
• Ability to communicate effectively both verbally and in writing.
• Ability to provide exemplary customer service at all times.
• Ability to interact positively with others and possess great interpersonal skills.
• Ability to multitask and perform well under pressure.
• Ability to have self-confidence.
• Ability to be a great team player.
• Ability to accept and learn from supervisor/peer critique.
• Ability to be flexible and adaptable to the changing needs of the organization.

Physical Demands:

While performing the essential functions of this position, the employee is regularly required to walk, sit, use hands and fingers, handle, or feel objects and equipment, reach with hands and arms, and communicate effectively by talking and hearing. The employee frequently must stand, climb, balance, stoop, kneel, crouch, or crawl and may occasionally use taste or smell. The employee must occasionally lift and/or move objects weighing up to 50 pounds.

Work Environment:

Work is performed in an office setting or outdoor work environment with moderate noise levels. Work environment may involve exposure to physical risks, such as blood borne pathogens, hazardous chemicals, or operating potential dangerous equipment, and requires adherence to all safety protocols. Required work schedules may include evening, weekend, overnight shifts, extended hours, or irregular schedules as operational needs dictate.  

As required by P.L. 93-638, absolute preference will be given to qualified Navajo applicants.  If there is no qualified Navajo applicant, preference will be given to qualified American Indian applicants.