Founded in 1906, McLeod Health is a locally owned and managed, not for profit organization supported by the strength of more than 900 members on its medical staff and more than 2,900 licensed nurses. McLeod Health is also composed of approximately 15,000 team members and more than 90 physician practices throughout its 18-county service area. With seven hospitals, McLeod Health operates three Health and Fitness Centers, a Sports Medicine and Outpatient Rehabilitation Center, Hospice and Home Health Services. The system currently has 988 licensed beds, including Hospice and Behavioral Health. The hospitals within McLeod Health include: McLeod Regional Medical Center, McLeod Health Dillon, McLeod Health Loris, McLeod Health Seacoast, McLeod Health Cheraw, McLeod Health Clarendon and McLeod Behavioral Health.  

Summary: The Senior Inpatient Coder is responsible for accurately assigning diagnosis and procedure codes to inpatient discharges at the larger McLeod Health facilities representing more complex medical/surgical encounters.

Maintains credentials as RHIA, RHIT or CCS with AHIMA is required. 

Possess inpatient coding knowledge and experience necessary to accurately assign codes to determine correct principal diagnosis, identify and assign co-morbidities and complications, secondary diagnoses, present on admission indicator, discharge disposition, Hospital Acquired conditions, principal procedure, and secondary procedures on all discharged inpatient records to arrive at the most appropriate DRG assignment. 

Codes all inpatient discharges at the 2 larger McLeod Health facilities (Florence & Seacoast) with more complex medical and surgical procedures.  These encounters involve longer lengths of stay, complex medical diagnoses and may involve extensive surgical procedures. These facilities provide the services like trauma, invasive cardiac, vascular, and complex orthopedic procedures that are not available at the smaller campuses

Maintains department specific productivity standards with a 95% accuracy rate.

Queries physicians appropriately when documentation is not clear in the medical record.

Must work closely with the Clinical Documentation Specialists to assure the most optimal DRG is assigned.

Keeps abreast of all new coding developments by attending any coding classes, reading articles on coding updates, and attending seminars when available.

Respect patient confidentiality at all times.

Performs other duties as assigned.

Work Schedule: 80 hours bi-weekly

Qualifications/Education/Training:

1 to 2 years of inpatient coding in an acute care hospital setting

Licenses and/or Certifications:

High School Diploma or equivalent preferred, Associate Degree preferred 

RHIT, RHIA, or CCS certification required