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We are looking for an Inpatient Coding Specialist to support accurate inpatient coding and clinical data abstraction for a Contract position based in Sacramento, California. In this role, you will evaluate inpatient medical records, assign diagnosis and procedure codes, and help ensure compliant reimbursement and reporting. The position requires close attention to documentation quality, regulatory standards, and timely account completion across the revenue cycle.
Job Responsibility
Examine inpatient charts and translate clinical documentation into accurate diagnosis and procedure codes using applicable classification systems and grouping methodologies
Determine the appropriate reimbursement grouping for each account while confirming discharge status, admission source details, and present-on-admission indicators are recorded correctly
Abstract required clinical and demographic data elements according to facility guidelines and regulatory reporting expectations
Review physician and care team documentation for completeness, identify missing or conflicting information, and pursue clarification when needed to support code assignment
Manage discharged-not-billed work queues to help move accounts through the revenue cycle within established turnaround expectations
Partner with clinical documentation improvement staff and providers to strengthen record completeness and support accurate severity and reimbursement outcomes
Apply coding, billing, and data collection rules consistently to maintain compliance with state, federal, and payer requirements
Use coding and validation tools such as Epic, 3M applications, encoders, audit platforms, and standard office software to verify information and complete assigned work
Maintain productivity and quality benchmarks while working independently, organizing priorities effectively, and resolving issues that affect coding accuracy or timeliness
Requirements
Hands-on experience coding inpatient medical records in a healthcare, hospital, or revenue cycle environment
Working knowledge of inpatient diagnosis and procedure coding standards, reimbursement groupers, and official coding guidance
Ability to interpret complex clinical documentation and abstract required information with a high level of accuracy
Familiarity with regulatory and payer requirements related to coding, billing, compliance, and data reporting
Proficiency with electronic health records and coding support tools, including systems such as Epic and 3M software
Strong communication skills with the ability to collaborate with providers, documentation specialists, and revenue cycle teams
Effective time management and organizational skills to balance productivity goals, queue management, and quality expectations
Detail-oriented approach with the ability to perform audits, verification activities, and independent problem-solving