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Coder 4 Inpatient

Company: Dignity Health
Location: Merced
Posted on: June 3, 2021

Job Description:


Mercy Medical Center, a Dignity Health member, has been building a rich history of care in our community for more than 100 years. We have grown from a small one-story wooden structure into a major healthcare provider with a new 186-bed main campus, offering the latest in facility design and technology. Mercy also operates Outpatient Centers, a Cancer Center and several rural clinics.

Wherever you work throughout our system, you will find faces of experience with dedication to high quality, personalized care. Joining our 1,300 employees, 230 physicians and many volunteers, you can help carry out our commitment to providing our community with the excellence they have come to associate with Mercy Medical Center.


Position Summary:

The Coder IV is a member of the Health Information Management Team responsible for ensuring the accuracy and completeness of clinical coding, validating the information in the databases for outcome management and specialty registries, across the entire integrated healthcare system. The purpose of this position is to apply the appropriate diagnostic and procedural codes to individual patient health information records for data retrieval, analysis and claims processing. This position is expected to perform duties in alignment with the mission and policies within the Dignity Health organization, TJC, CMS, and other regulatory agencies.

Principle Duties and Accountabilities:

  • Assign codes for diagnoses, treatments, and procedures according to the appropriate classification system for inpatient admissions.
  • Can also code ancillary, emergency department, same-day surgery, and observation charts if needed.
  • Review provider documentation to determine the principal diagnosis, co-morbidities and complications, secondary conditions and surgical procedures following official coding guidelines.
  • Utilize technical coding principals and APC reimbursement expertise to assign appropriate ICD-IO-CM diagnoses, ICD-IO-PCS as appropriate, and CPT-4 for procedures.
  • Understanding of ICD10 Coding in relation to DRGs
  • Abstract additional data elements during the chart review process when coding, as needed
  • Utilize technical coding principals and MS-DRG reimbursement expertise to assign appropriate ICD-10- CM diagnoses and ICD- IO-PCS procedures.
  • Ensure accurate coding by clarifying diagnosis _and procedural information through an established query process if necessary.
  • Assign Present on Admission (POA) value for inpatient diagnoses.
  • Extract required information from source documentation and enter into encoder and abstracting system.
  • Identifies non-payment conditions; Hospital-Acquired Conditions (HAC), Patient Safety Indicators (PSI) following, report through established procedures.
  • Collaborate in the DRG Mismatch process with the Clinical Documentation Improvement team.
  • Review documentation to verify and when necessary, correct the patient disposition upon discharge.
  • Prioritize work to ensure the timeframe of medical record coding meets regulatory requirements.
  • Serve as a resource for coding related questions as appropriate.
  • Adhere to and maintain required levels of performance in both Coding accuracy and productivity.
  • Review and maintain a record of charts coded, held, and/or missing
  • Provide documentation feedback to Providers, as needed
  • Participate in Coding department meetings and educational events.
  • Meet performance and quality standards at the Coder III level.
  • Abide by the Standards of Ethical Coding as set forth by the American Health Information Management Association (AHIMA) and adheres to official coding guidelines.
  • Other duties as assigned that have a direct impact on our ability to decrease the DNFB and support Revenue Cycle, including but not limited to charge validation, observation calculations, etc..



  • 3 years of relevant coding and abstracting experience or equivalent combination of education and experience required in an acute care hospital setting


  • Completion of an AHIMA or APPC accredited coding certification program that includes courses that are critical to coding success such as: Anatomy and physiology, pathophysiology, pharmacology, Anatomy / Physiology, Medical Terminology and ICD-10 and CPT coding courses etc.
  • High School Diploma or equivalent required

Required Qualifications:

  • Have and maintain current coding credential from AHIMA or AAPC (RHIA, RHIT, CCS, CCS-P, CPC, or CPC-H )
  • A minimum of 3 years Inpatient medical coding experience (hospital, facility, etc.)*
  • Must have ICD-10 coding experience
  • Must have experience with DRG coding
  • Ability to use a PC in a Windows environment, including MS Word and EMR systems
  • Ability to pass all pre-employment requirements including, but not limited to: drug screening, background check, and coding technical assessment
  • One year of experience will be waived for those who have attended the Dignity Health Coding Apprenticeship Program.*

Preferred Qualifications:

  • Experience with various Encoder systems (i.e., OptumCAC, Cerner)
  • Experience working in a 200 or greater bedside acute care hospital or hospital system
  • Intermediate level of Microsoft Excel
  • 5+ years inpatient medical coding experience (hospital, facility, etc)

Knowledge, Skills and Abilities:

  • Analytical / Critical thinking and problem solving
  • Knowledge and application of ICD-10-CM, ICD-10-PCS, HCPCS and CPT-4 classification systems
  • Excellent written and verbal communication skills, including the ability to present ideas and concepts effectively across organizational levels
  • Knowledge of information privacy laws, access, release of information, and release control technologies
  • Knowledge of hospital protocols and procedures
  • Working knowledge of functional relationships between departments within a healthcare or similar environment
  • Knowledge of TJC, HIPAA, HCFA, Title 22, security principles, guidelines, and standard healthcare practices
  • Demonstrated competence with personal computers, networks, and Microsoft Office

This position is an on-site position, remote work option is not available.

Keywords: Dignity Health, Merced , Coder 4 Inpatient, Other , Merced, California

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