Inpatient Coding Specialist

Singing River Health System

Job Description

The Inpatient Coding Specialist analyzes and interprets documentation in the medical record and abstracts the data elements in the electronic medical record. He/She assigns diagnosis-related groups (DRGs) and ambulatory payment classifications (APCs); completes abstracts for patient data; and works with all medical records regarding coding diagnoses and procedures. The Coding Specialist ensures the accuracy and completeness of assigned diagnosis and procedure codes and validates against the clinical documentation and claim data, establishing principal/primary diagnoses and secondary diagnoses.

High School diploma or equivalent required. Must have completed course work in medical terminology, anatomy, physiology, disease processes, ICD-10-Clinical Modification coding, and/or CPT coding. Associate's degree as a Registered Health Information Technician(RHIT) and/or Bachelor's degree as a Registered Health Information Administrator (RHIA) preferred.


Certified (or certified within one year of employment) by the American Health Information Management Association (AHIMA) or American Academy of Professional Coders (AAPC) as a:
CCS: Certified Coding Specialist
CIC: Certified Inpatient Coder
COC: Certified Outpatient Coder
RHIA: Registered Health Information Administrator
RHIT: Registered Health Information Technician
Or other equivalent coding certification

Once certified, employee must complete all requirements (including continuing education) to maintain certification.

Two (2) years coding experience directly applying codes required.

Physical Demands
Work is mainly sedentary: involves sitting most of the time with regular requirements to move about the office, move about the facility, and to travel to another facility within the SRHS service area. Work involves exerting a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. Work involves using repetitive motions: substantial movements of the wrists, hands and/or fingers while operating standard office equipment such as computer keyboard copier and 10-key.

Work involves being able to perceive the nature of sound at normal speaking levels with or without correction; the ability to make fine discriminations in sound. Work requires close visual and acuity and the ability to adjust the eye to bring an object into sharp focus, i.e. shift gaze from viewing a computer monitor to forms/printed material that are closer to compare data at close vision.

Must be able to be active for extended periods of time without experiencing undue fatigue. Must be able to work flexible hours.

Mental Demands
Must demonstrate keen mental faculties/assessment and decision making abilities. Must demonstrate superior communication/speaking/enunciation skills to receive and give information in person and by telephone. Must demonstrate strong written and verbal communication skills. Must possess emotional stability conducive to dealing with high stress levels. Must demonstrate ability to work under pressure and meet deadlines.

Must maintain a respectable working relationship throughout the organization. Must demonstrate the ability to code and abstract medical records and understand principles of coding/sequencing diagnoses. Must be able to communicate effectively with physicians regarding assignment of diagnoses and validation of codes in the medical record. Must have knowledge of anatomy, physiology and medical terminology; and have knowledge of DRGs/APCs.

Must successfully pass the Medical Records Coding tests (CPT and ICD-10) with a score of at least 70%.

Special Demands
Must possess superior customer service skills and professional etiquette. Must possess proficient knowledge and ability to use a computer (must be keyboard proficient) and other office technology (i.e., telephone, fax, etc.). Must have knowledge and skill in using MS Excel. Must have working knowledge of MS Outlook, Word, and PowerPoint. Job requires traveling throughout the SRHS service area with the employee providing his/her own transportation. Must have a valid driver license.

Work requires the ability to function independently, adapt to workload demands, set priorities, and understand and set goals. Must possess highly developed organizational, planning and management writing skills. Must understand the fundamentals of automated data processing, and be able to quickly gain a detailed understanding of complex computerized and non-computerized information.