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Beth Israel Lahey Health MEDICAL RECORDS INPATIENT CODER/ABSTRACTOR in Plymouth, 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)

40hpw; Day Shift; Monday-Friday; Remote position

Job Description:


Reads patient records and, as needed, discusses patient conditions with physicians/clinical

Documentation improvement specialist to accurately and completely apply diagnostic, procedural

and service codes to each patient condition treated (including operations) during an inpatient and/

or outpatient encounter. Abstracts clinical data from the patient record and enters into computer

databases. Serves as the source of clinical data for reimbursement, planning, and research.

Competently codes/abstracts inpatient and/or outpatient records.

  • Analyzes patient medical records and interprets documentation to identify all diagnoses and

procedures. Assigns proper ICD-10-CM/PCS and/or CPT diagnostic and operative procedures to

charts and related records by reference to designated coding manuals and other references


  • Codes and abstracts records consistently with 95% accuracy.

  • Prioritizes work to ensure timely submission to billing system.

  • Applies Uniform Hospital Discharge Data Set definitions to select the principal diagnosis, principalprocedure and other diagnoses and procedures which require coding, as well as other data items required to maintain the Hospital database.

  • Verifies that coded information is entered into the databases without any errors.

  • Applies sequencing guidelines to coded data according to official coding rules to determine the appropriate DRG assignment.

  • Assesses the adequacy of medical record documentation to ensure that it supports the principaldiagnosis, principal procedure, complications and comorbid conditions assigned codes. Consults with the appropriate physician and Clinical Documentation team or appropriate parties to clarify medical record information.

  • Identifies any documentation inadequacies with physician and/or appropriate parties and clarifies medical record information with courtesy and tact.

  • Keeps abreast of reimbursement reporting requirements, ie: POA, medical necessity policies.

  • Answers physician/clinician questions regarding coding principles, DRG assignment. Assists Finance, Data Processing and other departments with coding issues.

  • Assists physicians and ancillary departments with coding questions with timeliness, courtesy and tact.

  • Ability to work collaboratively in small teams to improve the operations of immediate work group by offering ideas, identifying issues, and respecting team members.

  • Remains abreast of developments in medical record technology by pursuing a program of Professional growth and development, attending educational programs and meetings, reviewingpertinent literature and so forth.

  • Utilizes professional affiliations, etc., in order to maintain current in professional developments.Attends pertinent coding seminars, when available

  • Maintains updated coding books.

  • Technology-Embraces technological solutions to work processes and practices.

  • Safety Awareness- Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment.

It is understood that this is a summary of key job functions and does not include every detail of the job that may reasonably be required.

Education/Experience Required:

  • Associate in Science Degree in Health Information and/or Certified Coding Specialist.

  • Two-three (2-3) years acute care hospital inpatient coding experience required.

  • Demonstrates in depth professional knowledge of ICD-10-CM/PCS, CPT-4, medical terminology, anatomy and physiology and DRG assignment.

  • Knowledge of MCR, MCD and 3rd Party coding requirements, including MS-DRGs, APR-DRGs and AP DRGS.

  • Successful passage of HIM Department Inpatient Coding Examination with grade of 80% or higher.

  • Detail oriented with strong interpersonal and organizational skills.

  • Strong computer skills with a good working knowledge of 3M coding software and Meditech Abstracting preferred.


  • CCS, CCS-P, CPC, or CPC-H

  • Registered Health Information Technician (RHIT), preferred, not required.

  • Registered Health Information Administrator (RHIA), preferred, not required.

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