Inpatient Lead Coder - Remote

BMC Software, Inc.

Job Overview

Location

Boston

Job Type

Full-time

Full Job Description

📋 Description

• Assigns appropriate codes to reflect all diagnoses and procedures extrapolated from physician and appropriate nursing documentation during a patient encounter according to the most current coding methodologies, including ICD-10-CM/PCS, resulting in appropriate reimbursement.
• Abstracts required data to input into the Medical Center's computerized data base.
• Converts all patient visits and encounters into appropriate DRG (Diagnosis Related Group) assignments in order to correctly submit the optimal reimbursement for each patient encounter coded.
• Assists the IP Coding Manager in administrative duties such as assignment of coding work, analysis of the unbilled report, and other duties as assigned.
• Abiding by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adhering to official coding guidelines and departmental procedures, the Team Leader, IP Coder:
• Assists IP Coding Manager with assignment of work to Coders, analysis of the daily unbilled report, and follow-up on unanswered physician queries and missing documentation.
• Assists PFS in researching unbilled accounts and updating incorrect discharge dispositions.
• Assists Coding Manager in orienting, training, and mentoring staff, provides ongoing education as needed.
• Assists IP Coding Manager as a resource and subject matter expert to outside departments.
• Assists IP Coding Manager trouble shooting system issues with 3M encoder and EPIC.
• Assists IP Coding Manager with special projects as needed.
• Reviews patient medical records and abstracts medical data that identifies all diagnoses and procedures.
• Codes diagnoses, procedures, and appropriate modifiers from the medical record documentation using ICD-10-CM/PCS classification systems.
• Refers to a computerized encoding system, written coding aids and other reference materials to ensure accurate coding for billing.
• Sequences diagnoses, procedures and complications by following ICD-10-CM/PCS and the Uniform Hospital Discharge Data Set (UHDDS); adheres to the Official Guidelines for Coding and Reporting, Coding Clinic guidelines and other regulatory guidelines as appropriate.
• Consults with the CDCI team to request appropriate physician or appropriate medical staff to clarify medical record information.
• Assigns grouper codes to each record according to patient type and financial class.
• Enters coded/abstracted information in grouper, analyzes groupings, and assigns the appropriate grouper for appropriate and accurate reimbursement.
• Data enters abstracted information into the Medical Center's computerized database.
• Maintains coding accuracy rate of 95% or better.
• Maintains productivity standards set forth in Departmental Policies and procedures.
• Coordinates with HIM to track missing provider documentation so that all records can be coded and billed in a timely fashion.
• Maintains professional skills and knowledge of coding through attendance at in-service programs, conferences, workshops and other educational programs and review of current literature.
• Assist in orienting new personnel to department coding procedures.
• Serves as resource for the Revenue Cycle Analysts in working claims in scrubber to clear for billing.
• Utilizes hospital’s behavioral standards as the basis for decision making and to facilitate the hospital’s goals and mission.
• Follows established Hospital infection control and safety procedures.
• Performs other duties as needed.

🎯 Requirements

• Level of knowledge equivalent to that ordinarily acquired through completion of an Associate's Degree in Health Information, Medical Records or similar program.
• Requires inpatient CCS, RHIT or RHIA credentials from AHIMA.
• Minimum of five years inpatient coding experience in a Level 1 Trauma, Teaching Facility.
• Work requires in-depth knowledge of medical terminology, ICD-10-CM/PCS and CPT-4 Coding conventions and knowledge of the various DRG systems (CMS DRGs, AP-DRG, and APR-DRGs).
• Experience with ICD-10-CM/PCS for diagnoses and procedures.
• Strong knowledge of health records, computer systems, Microsoft applications, data integrity, and processing techniques required.
• Excellent organizational skills, including ability to multi-task, prioritize essential tasks, follow-through and meet timelines.
• Ability to work with accuracy and attention to detail.
• Ability to solve problems appropriately using job knowledge and current policies/procedures.
• Ability to work cooperatively with members of the healthcare delivery team and staff, ability to handle frequent interruptions and adapt to changes in workload and work schedule and to respond quickly to urgent requests.
• Must be able to maintain strict confidentiality of all personal/health sensitive information and ensure compliance of HIPAA rules and regulations.
• Solid (or could use excellent again) communication skills, both oral and written.

🏖️ Benefits

• Compensation Range: $62,500.00- $91,000.00

Skills & Technologies

Senior

Remote

Degree Required

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BMC Software, Inc.

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About BMC Software, Inc.

BMC Software, Inc. develops and markets enterprise software for IT service management, automation, and optimization. Founded in 1980 and headquartered in Houston, Texas, the company provides solutions for mainframe, cloud, and DevOps environments, helping organizations manage digital operations, secure assets, and deliver services efficiently. Its portfolio includes Helix, Control-M, and MainView platforms. BMC serves Fortune 500 companies and government agencies across finance, healthcare, and telecommunications sectors, focusing on reducing IT costs, ensuring compliance, and accelerating innovation through automated workflows and data-driven insights.

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