Coder - Full-Time


 Under the System Director Health Information Management supervision, the coder will maintain professional certification while demonstrating a working knowledge of LTC MS-DRGs, APR-DRGs, ICD-9-CM, ICD-10-CM, and CPT coding requirements. The coder will be directly responsible for admission, concurrent and discharge coding, meeting the facility coding turnaround times, abstracting, coding query compliance, working with CDI to improve physician documentation and metrics utilization.


  •  Adheres to the turnaround times designated by Nexus for timely and accurately coding, timely communication of DRG assignment and updates, and claim creation for timely billing. The coder is responsible for assigning principal diagnosis within 24 hours of H&P completion, daily concurrent abstracting and review, and final DRG and code assignment within 72 hours of discharge.
  • Accurately abstracts and audits medical records for documentation compliance and accuracy to reflect accurate code assignment to support illness severity and service intensity.
  • Recognizes the role of a coder and how it relates to the overall clinical function of the hospital regarding correct documentation of patient care and fiscal reimbursement.
  • Identifies documentation improvement areas through admission, concurrent, and discharge abstracting and utilizes coding queries to meet specific coding guidelines.
  • Creation, implementation, and tracking of coding query compliance for physicians.
  • Plays an active role in the weekly DRG multi-disciplinary meetings to educate and gain clinical knowledge that can be utilized to optimize DRG assignment and documentation.
  • Accurately updates HIM Statistics related to admission, discharges, code assignment, final CMI, and LOS data. Keeps track of LOAs and updates DRG spreadsheet daily.
  • Consistently demonstrates the ability to promptly recognize, establish, and deal with issues. Strives to meet daily deadlines and demonstrates good time management skills, and participates in special projects and studies as assigned.
  • Maintain a 90% accuracy rate on coding audits performed monthly. Five percent of discharges will be audited monthly.
  • Assistance with RAC and third-party audit reviews related to coding and documentation issues.
  • Identifies and works towards resolutions of problems with charts or physicians that can cause delays with coding and/or clinical care.
  • Takes initiative to self-educate on the latest federal, state, and accreditation guidelines related to HIM and coding. Actively uses coding clinic and latest coding guidelines and conventions for accurate code assignment.
  • Utilizes and completes all 3M education coding modules for ICD-10
  • Works closely with the facility to ensure administration, case management, and the liaisons are aware of all coding changes and documentation barriers.
  • Attends coding round tables, meetings, and in-services and assigned.
  • Performs other duties as assigned.
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Job Requirements


  • Minimum of 4 years experience with inpatient ICD-9-CM and PCS coding and CPT coding. Long Term Acute Care coding experience preferred.
  • Working knowledge of LTC-MS-DRGs, APR-DRG’s, coding query utilization, and documentation improvement practices.
  • ICD-10 Training completed. Dual coding experience preferred.

Education Required

  • Completion of a 2 or 4 year accredited Health Information Management degree program preferred.

Additional Information


  • RHIA, RHIT, or CCS with certification maintenance
  •  Maintain current certification in good standing during employment with this facility, or obtain within thirty (30) days of hire