Job Description:
Hospitalist Medical Coder Position Summary The Hospitalist Medical Coder is responsible for accurate, compliant assignment of ICD-10CM, CPT, and HCPCS codes for inpatient and observation encounters performed by hospitalist providers. This role focuses on Evaluation & Management (E&M) services across the full episode of care, including admissions, subsequent visits, consultations (when applicable), discharge services, and select procedures. The coder applies current CPT, CMS, Official Coding Guidelines, and industry standard requirements to ensure complete and compliant coding that supports accurate reimbursement and withstands audit scrutiny.
Core Responsibilities Coding & Compliance
- Assign ICD-10-CM, CPT, and HCPCS codes for: o Initial hospital care and observation services o Subsequent hospital/observation visits o Same-day admit/discharge encounters o Discharge management services o Split/shared visits o Critical care services o Select bedside procedures (e.g., LP, paracentesis, thoracentesis when within scope)
- Apply 2023+ E&M guidelines using MDM and/or time, as appropriate.
- Accurately capture diagnoses reflecting severity, acuity, and resource utilization.
- Identify missed charge opportunities and documentation gaps.
- Ensure compliance with NCCI edits and other regulations. Documentation Review & Provider Support
- Review inpatient records including H&P, progress notes, consults, diagnostic results, procedure notes, and discharge summaries.
- Recognize documentation deficiencies impacting code assignment and escalate through established query workflows. Quality & Audit Alignment
- Maintain coding accuracy aligned with organizational benchmarks.
- Respond to internal and external audit findings and implement corrective feedback.
- Participate in focused reviews and coding validation initiatives as needed. Operational Performance
- Meet established productivity and turnaround-time standards.
- Prioritize workflow based on discharge-driven timelines and client SLAs.
- Maintain proficiency with EMR, encoder, and workflow platforms. Regulatory & Compliance Responsibilities
- Adhere to all applicable federal and state regulations and industry standards, including HIPAA, CMS program requirements, and the OIG Work Plan focus areas relevant to inpatient and professional fee services.
- Maintain strict confidentiality and appropriate use of PHI in all systems, communications, and workflows.
- Apply current CMS, AMA CPT, and Official Coding Guidelines in daily coding decisions.
- Follow organizational policies related to data security, remote work environments, and access controls.
Qualifications Required
- 2+ years of professional fee coding experience, including inpatient E&M. Active credential: CPC, CCS-P, or equivalent.
- Strong knowledge of: o Medical terminology, anatomy, and physiology o Hospitalist workflows and encounter sequencing o E&M MDM framework (2023+) o Critical care requirements o Split/shared billing rules A bachelor’s or associate degree in Health Information Management, Health Sciences, or a closely related Allied Health field is preferred. Preferred
- Prior hospitalist coding experience.
- Familiarity with Cerner, Epic, Meditech, Sunrise, or similar EMRs.
Key Competencies
- Strong clinical reasoning and attention to detail Sound judgment in complex E&M scenarios Consistency in applying guidelines across providers Clear written communication for queries and escalations Ability to operate independently in high-volume workflows
Pay: From ₹25,000.00 per month
Benefits:
- Health insurance
- Leave encashment
- Life insurance
- Provident Fund
Work Location: In person
