Urgent Requirement Inpatient DRG & CDI Coders

Urgent Requirement Inpatient DRG & CDI Coders Job Description: The "Clinical Document Integrity Specialist" and "Inpatient Revenue Translator" in the health information management (HIM) department is the Inpatient DRG/CDI Coder. Reviewing intricate inpatient medical records and converting lengthy clinical charts including physician notes, operation summaries, and pathology reports into accurate alphanumeric medical codes (ICD-10-CM/PCS) is your main responsibility. In your capacity as the "DRG Validation Authority," you make sure that the recorded diagnoses and procedures appropriately support the degree of disease and mortality risk before mapping the charts to the appropriate Medicare Severity Diagnosis Related Group (MS-DRG) or All Patient Refined DRG (APR-DRG). In order to protect against downstream payer audits and stop revenue leakage, the ideal candidate works with clinical precision, bridging the gap between clinical documentation improvement (CDI) specialists and medical coders. Key Duties Thorough Inpatient Chart Review: Examine intricate, multi-day inpatient electronic health records (EHR) in order to decipher a great deal of clinical information, test findings, and imaging reports. ICD-10-CM & PCS Code Assignment: To capture all primary diagnoses, secondary diagnoses, co-morbidities, and significant complications, assign precise ICD-10-CM diagnostic codes and ICD-10-PCS procedural codes. DRG Calculation & Validation: To determine the best and most accurate MS-DRG or APR-DRG assignment while increasing provider compliance and lawful revenue optimization, validate the major diagnostic selection. Clinical Documentation Improvement (CDI) Collaboration: Examine charts with CDI Specialists either in real time or in the past. Look for unclear or missing documentation and create clear, non-leading physician questions. CC/MCC Capturing: To make sure the record accurately depicts the patient's actual degree of disease, identify and separate Complications or Comorbidities (CC) and Major Complications or Comorbidities (MCC). We invite you to apply and explore this exciting opportunity! Warm Regards, HR - Maria