Inpatient Complex Coder

Company Description

At Henry Ford Health, we're committed to advancing health and improving lives for the millions of people we serve across Michigan and around the world. As one of the nation's leading academic health systems, we provide a comprehensive continuum of care that includes primary and preventive services, specialty and complex care, virtual care, pharmacy, home health, eye care, health insurance, and more. With 12 hospitals and hundreds of ambulatory care locations, including former Ascension Southeast Michigan and Flint Region facilities, our growing network expands access to exceptional care in the communities we serve.

Headquartered in Detroit, Henry Ford Health is helping shape the future of healthcare through the transformative Future of Health: Detroit initiative, a $3 billion investment that is redefining our academic healthcare campus and advancing innovation, research, education, and community impact.

Our work is grounded in purpose, collaboration, and belonging. We empower team members to grow their careers, contribute innovative ideas, and make a meaningful difference every day. Whether you're caring for patients, supporting operations, conducting research, or driving new solutions, you'll be part of a team united by a shared mission: delivering exceptional care, advancing health outcomes, and building healthier communities for all.

Job Description

GENERAL SUMMARY:

As an Inpatient Complex Coder, you'll be the critical link between clinical documentation and accurate healthcare reimbursement. You'll review, analyze, and code diagnostic and procedural information from patient medical records with precision and expertise. Your work directly impacts reimbursement accuracy, supports vital medical research, and enables data-driven administrative decisions that enhance patient care. By ensuring compliance with coding guidelines, third-party policies, and accreditation standards, you'll help optimize reimbursement while maintaining the integrity of our healthcare data systems.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

1. Conduct Comprehensive Medical Record Reviews
Thoroughly examine complete patient medical records—including histories, physicals, operative reports, pathology reports, therapy notes, nursing documentation, and discharge summaries—to identify all diagnostic and operative procedures and pertinent patient stay data. Verify documentation completeness and proactively request additional information to ensure full compliance with coding standards.

2. Assign Accurate Diagnostic and Procedural Codes
Apply established coding principles and guidelines to assign precise diagnostic and procedural codes using encoder software, ensuring every code reflects the clinical reality documented in the patient record.

3. Optimize MS-DRG Assignment and Sequencing
Identify the appropriate principal diagnosis and sequence all secondary diagnoses and procedures according to MS-DRG reimbursement system guidelines. Leverage your knowledge of optimization strategies to ensure accurate DRG assignment for all patients.

4. Ensure Medical Record Completeness
Verify the completeness of medical records within the electronic medical record system and promptly report any discrepancies to your supervisor to maintain data integrity.

5. Complete Discharge Abstracts
Compile comprehensive discharge abstracts by gathering pertinent patient stay data and integrating coded diagnostic and procedural information into our database systems.

6. Maintain Compliance and Professional Standards
Stay current with applicable Federal, State, and local laws and regulations. Uphold our Organizational Integrity Program and Standards of Conduct, demonstrating honest, ethical, and professional behavior in all coding activities.

7. Support Remote Coding Operations (if applicable)
If participating in our remote coding program, adhere to all Remote Coding Program policies and procedures.

8. Perform Additional Duties as Needed
Contribute to team success by completing other related duties as assigned.

Qualifications

EDUCATION/EXPERIENCE:

• Degree in Medical Record Sciences preferred but not required or successful completion of a certification program with certification as a Registered Health Information Technician (RHIT), Registered Health Administrator (RHIA), CCS Certified Coding Specialist or CCA Certified Coding Associate.  If RHIT, RHIA certification eligibility certification must be obtained within six (6) months of employment and a signed statement attesting to this agreement must be obtained upon hire. Must have a thorough knowledge of anatomy, physiology, pathophysiology, disease processes, medical terminology, pharmacology, and coding systems.
• Prior coding experience preferred but not required

CERTIFICATIONS/LICENSURES REQUIRED: 

• RHIA, RHIT, CCS or CCA certification

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Additional Information

This position is fully remote with flexible hours once trained.