Inpatient Coder

Aurora Health Care

Job Description:

  • Responsible for the coding and abstraction of inpatient and day surgery cases.
  • Assigns codes and abstracts inpatient and day surgery procedures and diagnoses using International Classification of Diseases (ICD), Procedure Coding
  • System (PCS) and Current Procedural Terminology (CPT) coding protocols for billing, reimbursement, statistical purposes and data collection.
  • Follows the prescribed organization’s coding guidelines.
  • Sequences diagnoses and procedure codes as outlined in the ICD Official Coding Guidelines, Uniform Hospital Discharge Data Set, the American Medical Association (AMA) CPT Assistant, and local and national requirements.
  • Reviews all provider documentation to include review of patient histories, physical examinations, emergency room visits, procedures, consultation and discharge summaries to support assigned codes in the health information record so that all significant diagnoses and procedures may be captured for reimbursement, statistical, research, severity and data purposes.
  • Follows up and obtains clarification on inaccurate documentation as appropriate.
  • Applies Medical Severity Diagnosis Related Groups (MS-DRGs) and Ambulatory Patient Categories (APCs) in order to code charts for accurate hospital bill preparation.
  • Reviews MS-DRG information from nursing worksheets for accuracy and forwards inaccurate information to appropriate leader as needed.
  • Compiles data for Center for Medicare Services (CMS) reporting of clinical indicators.
  • Abides by the Standards of Ethical Coding as set forth by the American Health Information Management Association and adheres to official coding guidelines. Practices ethical judgment in assigning and sequencing codes for proper insurance reimbursement.
  • Maintains the confidentiality of patient records. Reports any perceived non-compliant practices to the coding leader or compliance officer.

Required Qualifications:

Licensure, Registration and/or Certification Required:

  • Coding Associate (CCA) certification issued by the American Health Information Management Association (AHIMA), and
  • Coding Specialist (CCS) certification issued by the American Health Information Management Association (AHIMA) needs to be obtained within 6 months.
  • Health Information Administrator (RHIA) registration issued by the American Health Information Management Association (AHIMA), or Health Information Technician (RHIT) registration issued by the American Health Information Management Association (AHIMA)

Experience Required:

No experience required

Knowledge, Skills & Abilities Required:

  • Advanced knowledge of ICD and CPT coding systems, G-codes, HCPCS codes, CPT modifiers, MS-DRGs and APC.
  • Demonstrated competency of inpatient coding obtained within 6 months of hire.
  • Advanced knowledge and understanding of anatomy and physiology, medical terminology, pathophysiology (disease process, surgical terminology and pharmacology). Knowledge of pharmacology indications for drug usage and related adverse reactions.
  • Intermediate computer skills including experience with Microsoft Office or similar applications.
  • Excellent communication and reading comprehension skills.
  • Ability to work with a high degree of accuracy and give attention to detail of the repetitive nature.
  • Ability to work independently and exercise independent judgment and decision making.
  • Ability to meet deadlines while working in a fast-paced environment.
  • Ability to take initiative and work collaboratively with others.

Preferred Qualifications:

Inpatient Coding experience in a large acute care facility.

Education Required:

Associate’s Degree (or equivalent knowledge) in Health Information Management or related field.


Competitive Benefits package to be shared during the interview process.

Instructions for Resume Submission:

Please apply on line at Aurora Health Care.

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