Coder III

Description Salary Range: $54.72 - $74.94 + applicable differentials Job Description Division: Revenue Cycle Job Title:Coder III – Per Diem Position Summary Job Code: 562 Coder III – Per Diem is a senior-level coding professional responsible for accurately assigning ICD-10-CM, ICD-10-PCS, and CPT/HCPCS codes for complex inpatient and outpatient encounters. This role ensures precise DRG assignment, optimal reimbursement, and compliance with federal, state, and commercial payor regulations. The Coder III serves as a subject-matter expert and provides guidance to clinical documentation, coding staff, and revenue cycle leadership to support accurate charge capture and reduce denials. Inaddition to performing the essential functions listed below, may also be assigned other duties as required. Statement of Accountability Reports to: Director of Health Information Management Qualifications 1. Education • Education Required: • Licensure • Work Experience • Skills/computer/ specific technical •Associate of Arts (AA) or Associate of Science (AS) degree in Health Information Technology. Other qualifications, miscellaneous 2. Licenses/Certifications Specify if qualifications are Required or Preferred Required: •Registered Health Information Technician (RHIT) and Certified Coding Specialist (CCS) or Certified Inpatient Coder (CIC). Desired: •Registered Health Information Administrator (RHIA). 3. Work Experience Required: •Previous ICD-10 coding experience in the Inpatient Hospital environment. ••••Proficiency with ICD-10-PCS for surgical coding. Experience with DRG validation and reconciliation. Knowledge of medical terminology. Minimum of three (5) years of experience in inpatient acute care coding. Desired: •Previous Health Information Management Department experience. •Experience with electronic medical records. 4. Skills/computer/specific technical Required: •Working knowledge of ICD-10 and CPT guidelines, conventions, and coding systems. •Working knowledge of data collection systems for medical records. Job Description Template – Revised 12/1/2025 1•••••Familiarity with encoder tools and EHR systems (Epic experience preferred). Familiarity with Joint Commission, OSHPD and Title 22 regulations regarding medical records. Comprehensive understanding of CMS, state regulations, and commercial payor policies. Detailed understanding of MS-DRG and APR-DRG methodologies. Ability to prepare written reports clearly and timely. 5. Other qualifications – Ability to work well and communicate effectively with persons of •varying educational and cultural backgrounds. Essential Job Responsibilities Achieving Results Key Components: assess, plan, evaluate, demonstrate initiative, quality of work, productivity 1. Assignaccurate and compliant ICD-10 CM/PCS and CPT/HCPCS codes for complex inpatient (including ICU, Trauma, and surgical) and high acuity outpatient encounters. 2. Validateand assign MS-DRGs and APR-DRGs, ensuring clinical and coding accuracy. 3. Determines,records, and abstracts other required data according to applicable State, federal, or hospital requirements 4. Reviewprovider documentation for completeness, specificity, and compliance with coding standards (AHA, AHIMA, CMS). 5. Identifydocumentation gaps and initiate compliant provider queries to clarify diagnoses, procedures, and severity. 6. Basedon case mix, codes approximately 22 – 25 total cases per hour. Demonstrates Skill 1. Highlevel of accuracy and attention to detail - Codes records with 97% accuracy rate; performs DRG assignment as appropriate, with accurate case mix index data. 2. Abilityto interpret complex clinical documentation - Records abstracted data in accordance with published standards with 97% accuracy. 3. Stronganalytical and problem-solving skills. Key Components: competency, job knowledge, organizational skills, analytical skill, management of information, employee & patient safety 4. Submitsaccurate and non-leading physician queries. 5. Adheresto coding guidelines and regulations. 6. Supportrevenue cycle initiatives, payor audits, and denial mitigation strategies. Planning & Coordinating Key Components: delegates, decision making, problem solving, management of resources 1. Communicateschanges in work volume and backlog to supervisor. Professionalism 1. Displaysgood judgment and a practical approach to problem solving. 2. Complies with hospital’s Patient First ethic at all times. 3. Maintains confidentiality of all hospital information.Safeguards protected health information from any intentional or unintentional disclosure. 4. Demonstrates teamwork and responds promptly to requests for help from co-workers. Key Components: dependability, interpersonal skills, teamwork, patient first ethic, customer service, communication skills, punctuality/attendance, receptiveness to criticism, judgment, confidentiality 5. Partner with CDI, Billing, Revenue Integrity (charge capture), and Compliance teams to resolve coding or documentation issues. 6. Displays courtesy to others at all times.Is considerate of others cultural and spiritual needs. Job Description Template – Revised 12/1/2025 27. Reports to work as scheduled, in compliance with hospital attendance and punctuality policies. 8. Communicate effectively with physicians and clinical leaders on best practices for documentation. Improving the Organization Key Components: performance improvement, quality initiatives 1. Participatesin performance improvement activities as required. 2. Followssafety policies at all times, helps to maintain a safe workplace. Self-Development Key Components: maintain license/certification, education and training 1. Completesannual mandatory events as required. 2. Maintainprofessional certifications. 3. Worksto improve knowledge on an ongoing basis. Regulatory Compliance Key Components: JCAHO, Title 22, OIG, HIPAA, State/Federal laws, hospital policies 1. Complieswith all applicable laws and standards in regards to confidentiality, privacy and security. 2. Complieswith department and hospital policies and procedures. Prepared by: Title: Directorof HIM/CodingDate: 12/3/25 Lucy Young Approved by: Title: VPRevenue Cycle Date: Date: Personnel Office Review: Revised Date:4/11, 9/15, 1/16, 12/25 Job Description Template – Revised 12/1/2025 3Physical Requirements Job # 562 Job TitleHealth Information Technician 1. PhysicalActivities – General description.Show average time (0 – 8 hours) per workday. a. Sitting: None/minimal (0-1) None/minimal (0-1) None/minimal (0-1) None/minimal (0-1) None/minimal (0-1) Occasional (1-2) Occasional (1-2) Occasional (1-2) Occasional (1-2) Occasional (1-2) Frequent (3-4) Frequent (3-4) Frequent (3-4) Frequent (3-4) Frequent (3-4) Continuous (5+ Hrs) Continuous (5+ Hrs) Continuous (5+ Hrs) Continuous (5+ Hrs) Continuous (5+ Hrs) b. Walking: c. Standing: d. Bending: e. Squat,kneel, crawl: 2. Weightlifted / force exerted.Show average time (0 – 8 hours) per workday: a. 0-25 lbs. (light): None/minimal (0-1) None/minimal (0-1) None/minimal (0-1) Pushing/Pulling Occasional (1-2) Occasional (1-2) Occasional (1-2) Frequent (3-4) Frequent (3-4) Frequent (3-4) Continuous (5+ Hrs) Continuous (5+ Hrs) Continuous (5+ Hrs) b. 26- 50 lbs. (med): c. 51 + lbs. (heavy): d. Describetype of activity: Reaching above shoulder level Lifting Carrying. e. Detailsof heaviest item/activity: Medical records 3. Repetitiveuse of hands. Show average (0 – 8 hours) / workday: a. Bothhands: b. Dominantonly: c. Dexterity: None/minimal (0-1) None/minimal (0-1) Simple grasping Occasional (1-2) Occasional (1-2) Power grasping Frequent (3-4) Frequent (3-4) Fine manipulation. Continuous (5+ Hrs) Continuous (5+ Hrs)) Describe any special activity: Computer work and handling charts. 4. Repetitiveuse of feet (other than walking/standing), . foot control.Show average time (0 – 8 hours) workday: a. Right Left Both None/minimal (0-1) Occasional (1-2) Frequent (3-4) Continuous (5+ Hrs) Describe any special activity: None. 5. Visionrequirements: Basic Vision Requirements; including Close Vision (clear vision at 20 inches or less) and Distance Vision (clear at 20 feet or more). Specific Vision Requirements: a. b. c. Color Vision (ability to identify and distinguish colors) Peripheral Vision (ability to observe up/down or left/right while eyes are fixed on a given point) Depth Perception (three-dimensional vision; ability to judge distances and spatial relationships) Describe any special vision requirement: None. 6. Hearingrequirements: Basic Hearing Requirements; including ability to hear alarms and pages, ability to hear communications, requests or instructions from patients, staff or public. Describe any special hearing requirement: None. 7. WorkEnvironment - This job requires exposure to the following environmental conditions: a. b. c. d. Blood or body fluids Wet, humid conditions (non-weather)f. Work near moving mechanical parts Fumes or airborne particles e. Toxic or caustic chemicals Outdoor weather conditions Extreme cold (non-weather) Extreme heat (non-weather) i. j. k. Electrical shock risk. Risk of radiation Vibration g. h. l. Noiselevel for work environment is: Very Quiet Quiet Moderate Loud Very Loud 8. Other(if applicable): Job Description Template – Revised 12/1/2025 4Job Hazard Analysis Department: HIM Job Code:562 Hazards Which May Be Encountered Injury Methods To Prevent Injuries Lifting Objects/Patients Back Injuries Understand A&P of back, causes of back pain, preventive approaches, use of aids when lifting. Hernias Preventive measures when lifting and use aids when lifting. Avoid undue speed.Use handrails.Clean up spills immediately. Slip/Trip/Falls Contusions, Sprains, Strains Fires & Natural Disasters Burns & All Types of Injuries Recognize possible causes of fires.Smoking materials, faulty equipment. Employees should educate patients.Compressed gasses are flammable & under pressure so must be handled with care.Workers need to be familiar with disaster plans and know exit routes. Electrical Hazards Assaults Shocks & Burns Be aware of unsafe equipment and appliances.Attend electrical safety classes and seek assistance if any unsafe areas are noted. Minor Injury to Death Employees need to be cognizant to potential dangers to ensure safety.Awareness of existing security measures and defensive behavior can protect employee from assaults. Needles & Sharps Cuts, Punctures, Lacerations Sharps should be discarded in designated containers.Employees should exam & handle soiled linens & similar items as if they contained hazardous items. Obstacles & Broken Objects Abrasions, Contusions,Arrange furniture to allow free movement about the room.Keep doors & drawers and Lacerations closed when not in use.Clean/discard broken objects properly (. broken glass should be swept up - not picked up with fingers). Possible Exposures to Infections Hepatitis/Tuberculosis/Cytomegalovirus/Varicella/AID S/Herpes/Staph Infections, Lice/Scabies/Rubeola Infection Use Infection Control procedures as defined in Infection Control manual.These include handwashing, protective clothing, knowing the risks.Label linens and wastes properly. Possible exposure to acids & other chemicals used within the hospital Refer to MSDS's Employees should follow procedures as explained in their department Hazardous Material training and refer to MSDS's before using/handling any chemical.Follow procedures and do not use any chemical without proper labeling. Job Description Template – Revised 12/1/2025 5Hazards Which May Be Encountered Injury Methods To Prevent Injuries Latex Dermatitis to death Alert supervisor if you feel that you are allergic to latex materials. Use non-latex gloves for sterile procedures. Soaps, Detergents, Cleaning Solutions Ergonomic Problems Dermatitis Follow Departmental procedures.Protective clothing is available if Dept. is unable to substitute agents that do not cause dermatitis. Wide Variety of Musculoskeletal nervous disorders Body mechanics, positioning of equipment/furniture, and repetitive actions can cause employees to experience a variety of physical problems.Employees should follow safe body mechanics as described in hospital education.Employees are encouraged to seek assistance from their supervisor if they feel a task is causing them to experience physical problems.Work site evaluation may be indicated and this should be discussed with manager. Possible Chemical Exposure Refer to MSDS's Employees work with a variety of chemicals within the lab setting.Employees receive training upon hire and also are expected to review the Chemical Safety Plan yearly.Employees are expected to follow safe working procedures as instructed. Possible exposure to radiation Sterility, Cancer, Shortened Life Expectancy When appropriate, employees should wear filmbadges (they are monitored routinely) and use lead aprons, gloves, or shields.Identify and appropriately manage radiation therapy patients and their secretions. Possible Exposure to Chemotherapeutic Agents Exposure to Video Display Terminals Refer to MSDS's Employees involved in preparation or administration of chemotherapy drugs have potential for exposure.Employees must undergo training in their department and should follow procedures as directed. Eye strain & stress in It is unknown if significant visual dysfunction results from long-term use of VDT's. addition to ergonomicProblems may be controlled with control of lighting and glare, the color contrast, complaints and workers should have adequately corrected vision.Employees should seek assistance from their supervisor if they feel VDT is causing problems for them. Job Description Template – Revised 12/1/2025 6 Washington Hospital Health System does not utilize any form of electronic chatting, such as Google chat for the purposes of interviewing candidates for employment. If you are contacted by any entity or individual attempting to engage you in this format, do not disclose any personal information and contact Washington Hospital Healthcare System.