Coder II

Job Description Summary

Under the direct supervision of the Hospital Coding Supervisor, the Coder II will be responsible for abstracting and coding medical record documentation across various departments, including inpatient, outpatient, clinic, and emergency services. This role involves selecting and sequencing the appropriate ICD-10-CM/PCS, HCPCS, and CPT-4 codes to ensure accuracy and compliance with coding guidelines. The Coder II will contribute to coding compliance by ensuring timely and accurate assignment of codes for diagnoses and procedures, including the final DRG assignment.

Adheres to coding compliance guidelines for assignment of complete, accurate, timely and consistent codes for diagnoses and procedures to include final DRG assignment.

Entity

Medical University Hospital Authority (MUHA)

Worker Type

Employee

Worker Sub-Type

Regular

Cost Center

CC002307 SYS - Hospital Coding

Pay Rate Type

Hourly

Pay Grade

Health-25

Scheduled Weekly Hours

40

Work Shift

Job Description

The coder/abstracter is responsible for accurate code assignment of all inpatient, outpatient, and emergency service diagnoses, procedures and conditions as indicated in the patient medical record.

Classification systems include ICD-10 and CPT edition, and all coding is in accordance with official coding guidelines from the American Medical Association, the American Hospital Association, and the American Health Information Management Association.

All work is carried out in accordance with the Revenue Cyle Department and MUSC approved policies and procedures.

Additional Job Description

Key Responsibilities:

Abstract Medical Records: Review and abstract medical record documentation from inpatient, outpatient, clinic, and emergency department settings.

Code Selection: Accurately select and sequence ICD-10-CM/PCS, HCPCS, and CPT-4 codes based on the medical record documentation.

Compliance Adherence: Follow coding compliance guidelines to ensure the assignment of complete, accurate, timely, and consistent codes for diagnoses and procedures.

Final DRG Assignment: Assign the final Diagnosis Related Group (DRG) for inpatient cases, ensuring accurate grouping and coding.

Documentation: Maintain detailed and accurate records of coding assignments and modifications, ensuring all coding decisions are well-supported by the documentation.

Continuous Learning: Stay updated with current coding standards, regulations, and industry changes to ensure ongoing compliance and accuracy.

Quality Assurance: Participate in quality assurance activities, including coding audits and reviews, to support continuous improvement in coding practices.

Qualifications:

• Must have one of the required credentials RHIA, RHIT, CCS or CPC.

• Minimum of 1 years of coding experience in a hospital setting.

• Proven experience in training or education, preferably in a healthcare environment.

• Expertise in ICD-10-CM/PCS, HCPCS, and CPT4 coding systems.

• Strong understanding of medical terminology, anatomy, physiology, and disease processes.

• Excellent communication and interpersonal skills with the ability to effectively convey complex information to diverse audiences.

• Detail-oriented with strong analytical and problem-solving skills.

• Ability to work both independently and collaboratively within a team environment.

• Proficiency in using electronic health record (EHR) systems and coding software.

If you like working with energetic enthusiastic individuals, you will enjoy your career with us!

The Medical University of South Carolina is an Equal Opportunity Employer. MUSC does not discriminate on the basis of race, color, religion or belief, age, sex, national origin, gender identity, sexual orientation, disability, protected veteran status, family or parental status, or any other status protected by state laws and/or federal regulations. All qualified applicants are encouraged to apply and will receive consideration for employment based upon applicable qualifications, merit and business need.

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