Inpatient Coding Specialist I (Remote)

About the role

This is a Stanford Health Care job. A Brief Overview

Responsibilities

• Reviews medical record documentation and accurately assigns appropriate ICD-10 diagnoses and procedure codes, leading to the assignment of the correct Medicare Severity-Diagnosis Related Group (MS-DRG) or All Patient Refined Diagnosis Related Group (APR-DRG).
• Verifies the patient's discharge disposition, assigns the correct sources of admission for state regulation reporting purposes, and ensures the appropriate Present on Admission (POA) indicators are assigned to each code.
• Abstracts required data per facility specifications.
• Maintains accuracy and maintains established quality and productivity standards.
• Ensures compliance with all appropriate coding, billing and data collection regulations and procedures.
• Utilizes appropriate software to validate information.
• Uses Epic, 3M Coding and Reimbursement System (Encoder), 3M CDIS, 3M Audit Expert, MS Office, and other software as appropriate to compile and validate medical information.

Requirements

• Three (3) years of progressively responsible and directly related work experience
• Successful completion of the Coder Proficiency Exam (pre-hire)
• Adaptability to and dealing with change and ambiguity
• Planning, organizing, prioritizing, working independently and meeting deadlines
• Compliance with the American Health Information Management Association’s Code of Ethics and Standards and applying Uniform Hospital Discharge Data Set (UHDDS) standards
• Establishing and maintaining effective working relationships
• Managing, organizing, prioritizing, multi-tasking and adapting to changing priorities
• Solving technical and non-technical problems
• Utilizing the ICD-10-CM/PCS and CPT-4 coding conventions to code medical record entries; abstracting information from medical records; reading medical record documentation; assigning accurate codes for grouping of MS-DRGs and APR-DRGs
• Knowledge of diagnosis/procedure DRG grouping schemes such as MS-DRGs and APR-DRGs
• Knowledge of health information systems for computer application to medical records
• Fostering effective working relationships and building consensus
• Working effectively with individuals at all levels of the organization
• Knowledge of CCI (Correct Coding Initiatives) and CMS compliance issues
• Knowledge of computer systems and software used in functional area
• Knowledge of standards and regulations pertaining to the maintenance of patient medical records; medical records coding systems; medical terminology; anatomy and physiology and study of diseases

Qualifications

• High School Diploma or GED
• RHIA - Registered Health Information Administrator or RHIT - Registered Health Information Technician or CCS - Certified Coding Specialist

Skills

• Excellent written and oral communication skills
• Strong time management, problem-solving, and communication skills
• High degree of independence in performance of responsibilities
• Good judgment and decision-making skills
• Adapts to and deals with change and ambiguity
• Complies with the American Health Information Management Association’s Code of Ethics and Standards and applies Uniform Hospital Discharge Data Set (UHDDS) standards
• Establishes and maintains effective working relationships
• Works effectively through and with others
• Manages, organizes, prioritizes, multi-tasks and adapts to changing priorities
• Solves technical and non-technical problems
• Utilizes the ICD-10-CM/PCS and CPT-4 coding conventions to code medical record entries; abstracts information from medical records; reads medical record documentation; assigns accurate codes for grouping of MS-DRGs and APR-DRGs
• Knowledge of diagnosis/procedure DRG grouping schemes such as MS-DRGs and APR-DRGs
• Knowledge of health information systems for computer application to medical records
• Fosters effective working relationships and builds consensus
• Works effectively with individuals at all levels of the organization
• Knowledge of CCI (Correct Coding Initiatives) and CMS compliance issues
• Knowledge of computer systems and software used in functional area
• Knowledge of standards and regulations pertaining to the maintenance of patient medical records; medical records coding systems; medical terminology; anatomy and physiology and study of diseases

Benefits

Not specified

Pay

Base Pay Scale: Generally starting at $61.34 - $69.10 per hour

Schedule

Full time Day - 08 Hour