Pro Fee Coder – Hospitalist

Overview

Job Description - Pro Fee Coder – Hospitalist

The Pro Fee Coder – Hospitalist will review clinical documentation to assign and sequence diagnostic and procedural codes for hospital-based inpatient and observation encounters to meet physician billing and reimbursement requirements. This role focuses on professional fee (pro-fee) coding for hospitalists, ensuring accurate Evaluation & Management (E/M) coding for initial, subsequent, and discharge visits, as well as compliant documentation to support medical necessity and coding integrity.

The Coder performs documentation review and assessment for accurate abstracting of clinical data and may interact with providers and clinical staff for clarification and education.

• Select and assign ICD-10-CM and CPT/HCPCS codes for hospitalist services, including:
  • Initial hospital care
  • Subsequent daily visits
  • Discharge management
  • Observation and admission-to-discharge same-day encounters
  • Critical care services (as applicable)
• Review and analyze provider documentation to ensure accurate E/M code selection based on time, complexity, and medical decision-making.
• Identify and resolve documentation gaps through provider queries and clarification when necessary.
• Ensure compliance with Medicare, Medicaid, and commercial payer guidelines for inpatient professional coding.
• Validate that diagnoses and documentation accurately reflect patient acuity and SOI/ROM.
• Maintain knowledge of split/shared and teaching physician guidelines applicable to inpatient settings.
• Abstract key data elements from the medical record to ensure accuracy, completeness, and quality of coded data.
• Collaborate with the client team and other coders to ensure consistency, accuracy, and adherence to quality standards.
• Maintain strict patient and provider confidentiality in compliance with HIPAA and regulatory standards.
• Participate in Savista and client staff meetings, trainings, and continuing education sessions as required.

• Required:
  • Active AHIMA (RHIA, RHIT, CCS, CCA) or AAPC (CPC, COC, CCS-P, or related specialty) credential.
  • Two or more years of recent hands-on coding experience in hospitalist, inpatient professional, or observation services.
  • Strong understanding of E/M leveling, time-based coding, and medical decision-making for hospital-based encounters.
  • Familiarity with split/shared visits, teaching physician documentation, and inpatient medical necessity requirements.
  • Proficiency in ICD-10-CM and CPT/HCPCS code sets and official coding guidelines.
  • Ability to code at 95% accuracy or higher while maintaining production standards.
  • Proficient in MS Office applications (Word, Excel, Outlook) and EHR systems such as Cerner, Epic, or similar.

• Prior experience coding for hospitalist groups, internal medicine, or inpatient acute care settings preferred.
• Associate degree in Health Information Management (HIM) or a related field, or equivalent education and experience.
• Familiarity with RCX, Cerner, 3M, or Next Gen systems (a plus).
• Experience coding high-volume hospitalist charts and communicating with providers for documentation improvement.
• Understanding of HCC and risk adjustment capture for inpatient coding.

About Medasource

Medasource has established and maintained relationships to meet IT staffing needs, offering contract, contract-to-hire, or permanent placement options. We customise our search based on your initiatives, culture, and technologies. With a national team of recruiters at 21 hubs, we strive to find the people best-suited for your business. Medasource is an equal opportunity employer that does not discriminate on the basis of race, color, creed, religion, national origin, ancestry, citizenship status, age, sex or gender, gender identity or gender expression, sexual orientation, marital status, military service and veteran status, disability, or any other characteristic protected by law.

Benefits & Perks:

Medasource offers competitive medical, dental, vision, HSA, Dependent Care FSA, and supplemental coverage with plans to fit each employee’s needs. A 401k plan with company match, paid time off, sick time, paid holidays, and an Employee Assistance Program (EAP) are available.

Pay Disclaimer:

The pay range for this job level is a general guideline and not a guarantee of compensation. Offers consider responsibilities, education, experience, knowledge, skills, abilities, internal equity, market data, bargaining agreements, and other factors.

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