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HIM Coder III – Inpatient

HIM Coder III – Inpatient (Fully Remote)

Remote Location

Full time


At Cleveland Clinic Health System, we believe in a better future for healthcare. And each of us is responsible for honoring our commitment to excellence, pushing the boundaries and transforming the patient experience, every day.

We all have the power to help, heal and change lives beginning with our own. That’s the power of the Cleveland Clinic Health System team, and The Power of Every One.

Location Cleveland

Facility Remote Location

Department HIM Coding-Finance

Job Code U99927

Shift Days

Schedule 8:00am-4:30pm

Job Summary

Join the Cleveland Clinic team, where you will work alongside passionate caregivers and provide patient-first healthcare. At Cleveland Clinic, you will work alongside passionate and dedicated caregivers, receive endless support and appreciation, and build a rewarding career with one of the most respected healthcare organizations in the world.

The Coder III position is dedicated to either hospital inpatient or hospital outpatient coding. Codes and abstracts clinical information from inpatient or outpatient charts for the purpose of reimbursement, research, and compliance with federal regulations and other agencies utilizing established coding principles and protocols. Inpatient: Identifies, reviews, and assigns complex ICD-10-CM codes, PCS, POA and PSI indicators for inpatient charts.

Outpatient: Identifies, reviews, and assigns complex ICD-10-CM codes and CPT for ambulatory surgery and observation charts.

The ideal caregiver is someone who:

  • Has excellent critical thinking skills.
  • Has EPIC experience.

Our HIM Coder III’s have the opportunity to advance to Coding Reimbursement Coordinators (CRC’s), Auditors and Supervisors based on background and coding knowledge. We have a dedicated education team that provides monthly education and CEUs for AHIMA and AAPC credential holders.

At Cleveland Clinic, we know what matters most. That’s why we treat our caregivers as if they are our own family, and we are always creating ways to be there for you. Here, you’ll find that we offer: resources to learn and grow, a fulfilling career for everyone, and comprehensive benefits that invest in your health, your physical and mental well-being and your future.

When you join Cleveland Clinic, you’ll be part of a supportive caregiver family that will be united in shared values and purpose to fulfill our promise of being the best place to receive care and the best place to work in healthcare.

Job Details


  • Clarifies complex discrepancies in documentation and coding and assures accurate ICD-10-CM and PCS coding/abstracting assignment for inpatient 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 for inpatient charts or APC assignment for outpatient charts.
  • 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. The Certified Outpatient Coder (COC) by American Academy of Professional Coders will be considered for the outpatient Coder III role.

Complexity of Work:

  • Coding assessment relevant to the work may be required.
  • Requires critical thinking skills, decisive judgment, and the ability to work with minimal supervision.

Work Experience:

  • A minimum of two years of experience abstracting, identifying, reviewing, and assigning complex ICD-10-CM, PCS codes, POA and PSI indicators, surgical complications for inpatient charts or CPT for outpatient charts 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:

  • Ability to perform work in a stationary position for extended periods.
  • Ability to travel throughout the hospital system.
  • Ability to work with physical records, such as retrieving and filing them.
  • Ability to operate a computer and other office equipment.
  • Ability to communicate and exchange accurate information.
  • In some locations, ability to move up to 25 lbs.

Personal Protective Equipment:

  • Follows Standard Precautions using personal protective equipment.