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Beth Israel Lahey Health Hospital Inpatient Coder II Remote position in Burlington, Massachusetts

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:


Scheduled Hours:


Work Shift:

Day (United States of America)

Under the direction of the Hospital Coding Manager or Supervisor, and exercising independent judgment within the scope of the job, the Hospital Inpatient Coder II assigns applicable ICD-10 Codes, Present on Admission (POA), Hospital Acquired Condition (HAC), and Patient Safety Indicators (PSI) using current industry standards, the Official Coding Guidelines, Coding Clinic, UHDDS and regulatory requirements.

Ensures the integrity and quality of patient data to achieve minimal variation in coding practices; assigns codes only as supported by physician/licensed independent practitioner (LIP) documentation within the body of the medical record. Applies in-depth knowledge of medical terminology and anatomy and physiology specific to coding.

This is a remote position.

Job Description:

Essential Duties & Responsibilities including but not limited to:

  • Reviews and abstracts diagnoses and procedures from physician and other providers medical record information including but not limited to, history and physical, discharge summary, progress notes, orders, operative notes/reports, pathology reports, nursing notes, and medications.

  • Selects and sequences principal, secondary, and procedure based on provider medical record information to ensure accurate DRG assignment and reimbursement.

  • Assigns applicable ICD-10 Codes, Present on Admission (POA), Hospital Acquired Condition (HAC), and Patient Safety Indicators (PSI) codes using current industry guidelines from (but not limited to), AHIMA, Coding Clinic, CMS, specific payers, Agency for Healthcare Quality and Research (AHRQ) and CDC (official coding guidelines).

  • Utilizes grouper software to assist with assignment of accurate codes and to calculate appropriate DRG for hospital reimbursement.

  • Applies a thorough knowledge of medical terminology, anatomy & physiology and coding systems to accurately assign diagnoses and procedures in accordance with department, hospital, and regulatory requirements.

  • Submits queries to providers as needed when a diagnosis or procedure has been determined to meet the guidelines for reporting but has not been clearly or completely stated within the medical record, when ambiguous or conflicting documentation is present, or when documentation is unclear for POA indicator assignment.

  • Acts as a resource to representatives from Patient Financial Services as needed to provide accurate coding/billing data and expedite the billing process.

  • Demonstrates efficiency in use of hospital information system by abstracting all information, codes and charges appropriately, including 3M, Epic, and Cobius.

  • Communicate issues with incorrect documentation and software inability to complete functions to Manager or Supervisor of Hospital Coding as needed.

  • Reviews denials in Cobius Denial Software and determine appropriate resolution based on audit.

  • Works with Clinical Decision Specialists regarding MD Queries and correlation of care.

  • Receives accounts from DRG Validator and adjusts accordingly for optimization of account

Organizational Requirements:

  • Maintains strict adherence to the Lahey Hospital and Medical Center Confidentiality policy.

  • Incorporate Lahey Hospital and Medical Center Standards of Behavior and Guiding Principles into daily activities

  • Comply with all Lahey Hospital and Medical Center Policies.

  • Comply with behavioral expectations of the department and Lahey Hospital and Medical Center.

  • Maintain courteous and effective interactions with colleagues and patients.

  • Demonstrate an understanding of the job description, performance expectations, and competency assessment.

  • Demonstrate a commitment toward meeting and exceeding the needs of our customers and consistently adheres to Customer Service standards.

  • Participate in departmental and/or interdepartmental quality improvement activities.

  • Participate in and successfully completes Mandatory Education.

  • Perform all other duties as needed or directed to meet the needs of the department.

Minimum Qualifications:

Education: Minimum High School degree or equivalent; college degree highly desirable.

Licensure, Certification & Registration Required: CCS or CIC

Experience: Minimum five years of hospital inpatient coding experience and/or an RN or other healthcare clinician with at least 5 years acute care experience (e.g., medical-surgical, ICU, case management, etc.).

Skills, Knowledge & Abilities:

  • Knowledge of Medical Terminology, Anatomy & Physiology, and coding clinical concepts such as gained from coding coursework.

  • Knowledge of payment methodologies including prospective payment (PPS), federal and state regulations.

  • Computer skills, including knowledge of Microsoft Office and encoder.

  • Ability to work in a high paced, high volume, multi-task environment.

  • Strong organization and communication skills.

FLSA Status:


As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) and COVID-19 as a condition of employment. Learn more ( about this requirement.

More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger.

Equal Opportunity Employer/Veterans/Disabled