Inpatient Auditor

Job Title: Inpatient Coder Department: Health Information Management (HIM) Reports To: Coding Manager / HIM Director Position Summary The Inpatient Coder is responsible for reviewing inpatient medical records and assigning accurate ICD-10-CM diagnosis codes and ICD-10-PCS procedure codes to ensure proper reimbursement, regulatory compliance, and data integrity. This role applies official coding guidelines and MS-DRG/APR-DRG methodologies to support accurate billing and quality reporting. Key Responsibilities • Review and analyze inpatient medical records to assign accurate ICD-10-CM and ICD-10-PCS codes • Assign and validate MS-DRG/APR-DRG groupings to optimize appropriate reimbursement • Abstract clinical data and ensure correct sequencing of principal and secondary diagnoses and procedures • Query physicians for clarification when documentation is incomplete, ambiguous, or conflicting • Maintain coding accuracy and productivity standards established by the department • Ensure compliance with CMS, Official Coding Guidelines, and other regulatory requirements • Identify and report documentation deficiencies and assist with CDI (Clinical Documentation Integrity) initiatives • Stay current with coding updates, payer requirements, and regulatory changes • Maintain patient confidentiality in accordance with HIPAA Qualifications Required: • High school diploma or equivalent • Coding certification: CCS (Certified Coding Specialist), RHIT, or RHIA • 1–3 years of inpatient coding experience in an acute care setting • Proficiency in ICD-10-CM/PCS and MS-DRG/APR-DRG methodologies • Knowledge of medical terminology, anatomy, physiology, and pathophysiology Preferred: • Experience with encoder software (e.g., 3M, Optum) and EHR systems (e.g., Epic, Cerner) • Experience with CDI collaboration Skills & Competencies • Strong analytical and critical-thinking skills • High attention to detail and accuracy • Ability to work independently in a remote or onsite environment • Effective written and verbal communication for physician queries Performance Standards • Coding accuracy rate of 95% or higher • Meets established productivity benchmarks (charts per day/hour) 4