13 days old

HIM Coder III - Inpatient

Cleveland Clinic
Cleveland, OH 44114

Job Summary:

Identifies, reviews, and assigns complex ICD-9-CM, ICD-10-CM, PCS codes, POA and PSI indicators, surgical complications, and CPT codes. Abstracts clinical information from inpatient/outpatient types for the purpose of reimbursements, research, and compliance with federal regulations and other agencies utilizing established coding principles and protocols.


This opening is specific to INPATIENT coding only. The preferred candidate is a graduate of an AHIMA accredited program and will have 3-5 years inpatient tertiary and trauma coding experience.  Experience with Epic and CAC is a plus.  This is a full-time REMOTE opportunity that offers flexible/creative schedules and monthly education sessions!


  • Clarifies complex discrepancies in documentation and coding and assures accuracy and timeliness of coding/abstracting assignments to expedite the billing process and to facilitate data retrieval for physician access and ongoing patient care.
  • Follows up on complex coding of medical records as a result of internal or external reviews which have identified Coding or DRG discrepancies.
  • Supports special studies in relation to coding and abstracting information according to policies and procedures.
  • Maintains knowledge and skills via written coding resources, clinical information, videos, etc.
  • Meets or exceeds productivity and quality standards and established department benchmarks.
  • Extracts pertinent information from clinical notes, operative notes, radiology reports, laboratory reports, (including Pathology), procedure records, specialty forms, etc.
  • Determines complex code assignment pertinent to diagnostic workups, surgical techniques, advanced technology and special services.
  • Identifies medical and surgical complications and untoward events for accurate MS-DRG / APR-DRG or APC assignment.
  • Other duties as assigned.


    • High School Diploma is required.


      • Registered Health Information Administrator (RHIA), Registered Health Information Technician (RHIT) or Certified Coding Specialist (CCS) is required and must be maintained.

        Complexity of Work:

        • Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.
        • Must be able to work in a stressful environment and take appropriate action.

          Work Experience:

          • A minimum of two years of experience abstracting, identifying, reviewing, and assigning complex ICD-9-CM, ICD-10-CM, PCS codes, POA and PSI indicators, surgical complications, CPT codes for inpatient/outpatient types is required.
          • Successful completion of the Cleveland Clinic Coder Trainee Program with a focus on moderately complex cases may offset the experience requirement.

            Physical Requirements:

            • Physical demands require standing, walking, sitting, lifting, carrying up to 25 lbs. Close, distant, and color vision is required.
            • Requires manual dexterity to grasp and handle records and to operate a PC computer in the course of work.
            • The work environment is at a moderate noise level (business office with phones, copiers, computers, and printers).

              Personal Protective Equipment:

              • Follows Standard Precautions using personal protective equipment. 

                The policy of Cleveland Clinic and its system hospitals (Cleveland Clinic) is to provide equal opportunity to all of our employees and applicants for employment in our tobacco free and drug free environment. All offers of employment are followed by testing for controlled substance and nicotine. Job offers will be rescinded for candidates for employment who test positive for nicotine. Candidates for employment who are impacted by Cleveland Clinic’s Smoking Policy will be permitted to reapply for open positions after 90 days. Decisions concerning employment, transfers and promotions are made upon the basis of the best qualified candidate without regard to color, race, religion, national origin, age, sex, sexual orientation, marital status, ancestry, status as a disabled or Vietnam era veteran or any other characteristic protected by law. Information provided on this application may be shared with any Cleveland Clinic facility.

                Cleveland Clinic is pleased to be an equal employment employer: Women/Minorities/Veterans/Individuals with Disabilities",


Posted: 2019-09-04 Expires: 2019-10-04

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HIM Coder III - Inpatient

Cleveland Clinic
Cleveland, OH 44114

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