I. General Summary

• Under direct supervision, accurately codes hospital inpatient accounts for the purpose of appropriate reimbursement, research, statistics and compliance to federal and state regulations in accordance with established ICD-10-CM/PCS coding classification systems.

II. Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

• Serves as a clinical coding subject matter expert, and utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed.
• Analyzes, codes and abstracts complex inpatient cases such as trauma, rehab, neurology, critical care, etc. utilizing the ICD-10-CM and ICD-10-PCS nomenclature to ensure accurate APR-DRG/SOI/ROM and POA assignment.
• Utilizes critical thinking to analyze and evaluate documentation issues with consultation from the medical and clinical staff, and clinical documentation specialists as needed.
• Collaborates with other senior coders (and the other coding staff) with sharing coding information and providing coding advice to colleagues regarding complex cases to be coded.

The University of Maryland Medical System is a 14-hospital system with academic, community and specialty medical services reaching every part of Maryland and beyond. UMMS is a national and regional referral center for trauma, cancer care, Neurocare, cardiac care, women’s and children’s health and physical rehabilitation. UMMS is the fourth largest private employer in the Baltimore metropolitan area and one of the top 20 employers in the state of Maryland. No organization will give you the clinical variety, the support, or the opportunities for professional growth that you’ll enjoy as a member of our team. 

III. Education and Experience

• High School graduate or equivalent. Formal ICD-10-CM and CPT training Associates or Bachelor’s degree preferred.
• Minimum of three years ICD-10-CM/ICD-10-PCS coding and abstracting experience with at a Level 1 Trauma and Rehab hospital or 4 years of experience with coding inpatient hospital medical records required.
• One of the following required: Certified Coding Specialist (CCS), Registered Health Information Technician (RHIT), Registered Health Information Administrator (RHIA), Certified Inpatient Coder (CIC)

IV. Knowledge, Skills and Abilities

• Strong analytical and organizational skills; filing systems; ability to prioritize workloads; meet deadlines and work effectively under pressure; excellent customer service skills; general office procedures; ability to problem solve and work with minimal supervision; familiar with basic medical terminology; computer experience; typing ability.

All your information will be kept confidential according to EEO guidelines.